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PROCEEDINGS 

OF  THE 

CONFERENCE  ON  AID  TO 

THE  VISUALLY  LIMITED 


American  Foundation 

FORTHEBLINDinc. 


1  '"•  Y-i  IQOix 


PROCEEDINGS 

OP  THE 
CONFERENCE  OM  AID  TO 
THE  VISUALLY  LIMITED 

****** 


The    objectives    of  this   Conference   were    to 

identify  the   needs, 
economic,    visual,    social,   vocational   and 
avocational , 
of  our   visually-limited  peoole 
and   to 
seek  ways  and  means 
by  which   those   needs   may  better  be   met. 

****** 


Sponsored  by 
THE  AMERICAN  OPTOMETRIC  ASSOCIATION 
through  its 
Committee  on  Aid  to  the  Partially-Sighted 

Charles  Margach,  Chairman 
Edwin  3.  Mehr  C.  Edward  Williams 

Alfred  A.  Rosenbloom    Douglas  P.  Wis man 

****** 


March  24  and  25,  1966 

American  Chemical  Society  Auditorium 
1155  16th  Street,  M.W. 
WASHINGTON!,  D.  C. 


vO 


O 

in 


SPONSORING  ORGANIZATIONS 

American  Optometric  Association 
California   Cytometric  Association 
Colorado  Optometric  Association 
Connecticut  Cytometric  Association 
Delaware  Optometric  Association 
District  of  Columbia  Optometric  Society 
Illinois  Optometric  Association 
Iowa  Optometric  Association 


Los  Angeles  College  of  Optometry 

Maryland  Ootometric  Association 

Massachusetts  Ootometric  Association 

Michigan  Optometric  Association 

Missouri  Optometric  Association 

(<1  New  Hampshire  Ootometric  Association 

New  York  State  Optometric  Association 
o 

North  Carolina  Optometric  Association 
Ohio  State  University,  School  of  Ootometry 

^_  Ontario  (Canada)  College  of  Optometry 

C 
£_  Oregon  Optometric  Association 

Pennsylvania  College  of  Optometry 

Pennsylvania  Ootometric  Association 

Rhode  Island  Optometric  Association 

Southern  College  of  Optometry 

Virginia  Optometric  Association 


AMERICAN    CYTOMETRIC    ASSOCIATION 
CONFERENCE    ON    AID   TO   THE   VISUALLY-LIMITED 
March  24   and  25,    1966 
American   Chemical   Society  Auditorium 
Washington,    D.    C. 


ROSTER 


Miss   Caroline   Austin,    M.A.,   Visual   Coordinator,    Public    Health 
Department,    State    of   Illinois,    Springfield,    Illinois 

Miss   Nancy  Boggess,   Division   for  the   Blind,    Library   of 
Congress,    Washington,    D.    C,    205*10 

Frank   Brazelton,    O.D.,    Los   Angeles   College    of  Optometry, 
950   W.    Jefferson   Street,    Los   Angeles,    California 

Larry   Brothers,   O.D.,    2014    S.    Main,   Joplin,    Missouri 

Miss    Sarah  Butts,    Medical   Services   Specialist,    Bureau   of 
Family  Services,   Medical   Services   Division,    U.S.    Deoartment 
of  Health,    Education   and  Welfare,    Room  4650,    North   Building, 
Washington,   D.    C. 

E.    S.    Budge,    Division    for  the    Blind,    Library   of  Congress, 
Washington,   D.    C,    20540 

R.    Wells   Campbell,    O.D.,    20   E.    Commerce    Street,    Smyrna,    Delaware 

Terence   E.    Carroll,   Director,   National   Institutes   on 
Rehabilitation   and  Health  Services,    1714   Massachusetts 
Avenue,   N.W.,    Washington,    D.    C. ,    20036 

Joseph   P.    Cortese,    O.D.,    2010   Washington   Street,    Wilmington, 
Delaware 

Herbert   E,    Cross,    Jr.,    O.D.,    101  N.    Columbus   Street, 
Alexandria,   Virginia 

Morton   Davis,   O.D.,    4304   East-West  Highway,   Bethesda, 
Maryland,   20014 

Mrs.    Frances   Dearman,    Science    Writer,    Information   Office, 
National   Institute    of  Neurological   Diseases    &  Blindness, 
N. I. H.    Building  31,   NIH,    PHS,    Bethesda,    Maryland,    496-5751 


ii 


Digitized  by  the  Internet  Archive 

in  2011  with  funding  from 

Lyrasis  Members  and  Sloan  Foundation 


http://www.archive.org/details/proceedingsofcOOamer 


John  K.  Dupress,  Managing  Director,  Sensory  Aids  Center, 
292  Main  Street,  Cambridge  38,  Massachusetts 

Mrs.  Henry  (Caroline)  Fales,  President,  Maryland  Association 
for  the  Visually  Handicapped,  6502  Stoneham  Road,  Bethesda, 
Maryland   EM  5-2189 

Richard  Peinberg,  Ph.D.,  Chief,  Visual  and  Auditory  Laboratory, 
Georgetown  Clinical  Research  Laboratory,  Federal  Aviation 
Agency,  Washington  25,  D.  C. 

E.  J.  Fisher,  O.D. ,  Dean,  College  of  Optometry  of  Ontario, 
140  St.  George  Street,  Toronto  5t    Ontario,  Canada 

The  Honorable  John  E.  Fogarty,  Representative  from  Rhode 
Island,  U.  S.  House  of  Representatives,  1235  Longworth 
House  Office  Building,  Washington,  D.  C. 

J.  F.  Follmann,  Jr.,  Director  of  Information  and  Research, 
Health  Insurance  Association  of  America,  750  Third  Avenue, 
New  York,  New  York   10017 

Jack  M.  Fugate,  O.D.,  Director,  Low  Vision  Clinic,  The  Ohio 
State  University,  School  of  Optometry,  Columbus,  Ohio 

Charles  Gallozzi,  Acting  Chief,  Reference  Department, 
Division  for  the  Blind,  The  Library  of  Congress,  Washington, 
D.  C.    20540 

Ernest  Gaynes,  O.D.,  Low  Vision  Clinic,  Sinai  Hospital  of 
Detroit,  6767  West  Outer  Drive,  Detroit,  Michigan   48235 

Miss  Helen  Gibbons,  Staff  Consultant,  National  Society  for 
the  Prevention  of  Blindness,  Inc.,  16  East  40th  Street, 
New  York,  N.  Y.    10016 

Harold  Glazier,  O.D. ,  4304  East-West  Highway,  Bethesda,  Maryland 

Hyman  Goldstein,  Ph.D.,  Chief,  Biometrics  Branch,  National 
Institute  of  Neurological  Diseases  and  Blindness,  Department 
of  Health,  Education,  and  Welfare,  Bethesda,  Maryland  20014 

Lt.  Col.  Billy  C.  Greene,  Chief,  Optometry  Section,  Office 
of  the  Surgeon  General,  Washington  25,  D.  C. 

Ralph  Gunkel,  O.D.,  Ophthalmology  Branch,  National  Institute 
of  Neurological  Diseases  and  Blindness,  Department  of  Health, 
Education  and  Welfare,  Bethesda,  Maryland   20014 

Arnold  H.  Gordon,  O.D.,  1302  S.  Washington,  Royal  Oak,  Michigan 


iii 


George   Hellinger,    O.D.  ,   Industrial  Home    for  the    Blind,   20   Park 
Avenue,    New  York    16,    New   York 

Henry  Hoff,    O.D.,    President,    The    Optometric   Society   of  the 
District    of  Columbia,    1712   Eye   Street,    N.    W.  ,   Washington,    D.    C. 

Lee    Holder,    Director,    Community   Action   Studies    Project, 
National  Commission   on   Community   Health   Services, 
7815   Old  Georgetown  Road,    Bethesda,    Maryland  20014 

Gertrude   Hunter,    M.D. ,   Medical  Specialist    for  Head  Start    Project, 
U.    S.    Office    of  Economic    Opportunity,    1200   Nineteenth   Street,    N.W. , 
Washington,    D.    C. 

Rubin   I.    Jaffe,    O.D.  ,    7   Islington  Street,   Portsmouth,   New  Hampshire 

Marie   A.    Jakus ,    Ph.D.,   Executive   Secretary,  Visual  Sciences   Study 
Section,    Division   of  Research   Grants,   National   Institutes   of 
Health,    Bethesda,    Maryland       20014 

Keith   Jennison,    Keith   Jennison   Books,    Inc.,    575   Lexington 
Avenue,    New   York,    New   York      10022 

J.    Arthur  Johnson,   Executive    Director,    Columbia  Lighthouse 
for  the    Blind,   2021   14th   Street,    N.    W.  ,   Washington,    D.    C. 

Mrs.    Kate    C.    Kern,    President,    Maryland  Federation   of  the 
Council   for  Exceptional   Children,    6709   Pyle    Road,    Bethesda, 
Maryland     20034 

Frank   M.    Kitchell,   O.D.,    74   Hilton   Avenue,   Hempstead,   Long 
Island,   New  York      11550 

Earl   T.    Klein,    Acting  Director,    Office   of  Evaluation  and 
Reports,   U.    S.    Department   of  Labor,    Office   of  Manpower, 
Automation   and  Training,   Washington,    D.    C.        20210 

Edmond  J.    Leonard,   Asst.    Director  of  Information,    The    President's 
Committee   on  Employment    of  the   Handicapped,    Department    of  Labor 
Building,    Room  7135,  Washington,    D.    C. 

Howard  Lewis,    O.D. ,    Central   Carolina  Bank  Building,    Durham, 
North   Carolina 

Captain   Arthur  Louis,    BSC,   USAF,   Andrews   AFB,    Washington,    D.    C. 

Mrs.    Helen   Lyman,    Public    Library   Specialist,    Adult    Services, 
Library  Services    Branch,    Office    of  Education,    Washington,    D.C.    20202 

Lewis    MacCracken,    Director  of  Membership    Relations,    American 
Optometric   Association,    7000    Chippewa  Street,   St.    Louis, 
Missouri      63119 


iv 


William  P.    MacCracken,    Jr.,    Washington   Counsel,    American 
Cytometric   Association,    1000    Connecticut    Avenue,    Washington, 
D.    C.        20036 

V.    Eugene    McCrary,    O.D.,    President,    American   Optometric 
Association,    4500    Beechwood   Road,    College    Park,    Maryland     20740 

D.    C.    MacFarland,    Ph.D.,    Chief,    Division   of   Services   to   the 
Blind,    Vocational   Rehabilitation   Administration,    Health, 
Education,    and   Welfare,    Washington,    D.    C. 

H.    E.    Mahlman,    Assistant    Director,    Washington   Office,    American 
Optometric    Association,    1026    17th   Street,    N.    W. ,    Washington, 
D.    C.  20036 

Charles    Margach,    O.D.,    College    of   Optometry,    Pacific    University, 
Forest   Grove,    Oregon 

Arnold  M.    Mazer,    O.D.  ,    l6l4    S.    Upsal   Street,    Philadelphia, 
Pennsylvania 

Frank   Maier,    O.D.,    Southern   College    of  Optometry,    1246   Union 
Avenue,    Memphis,    Tennessee 

Edwin    B.    Mehr,    O.D.,    1240   Scott    Boulevard,    Santa   Clara, 
California        95050 

Joseph   Meyers,    Deputy   Commissioner  of   Welfare,    Welfare 
Administration,    Health,   Education,    and  Welfare,    Washington,    D.C. 

Stanley   Mroz ,    O.D.,    Pennsylvania   College    of   Optometry,    6100 
North    12th   Street,    Philadelphia   41,    Pennsylvania 

Eugene    Murphy,    Ph.D.,   Chief,    Research   and   Development    Division, 
Prosthetic    &   Sensory   Aids   Service,    Department    of   Medicine   and 
Surgery,   Veterans    Administration,    252    Seventh   Avenue,    New   York, 
New   York  10001 

John   F.    Nagle,    Chief,    Washington   Office,    National   Federation   of 
the    Blind,    1908   Que    Street,    N.    W. ,    Washington    9,    D.    C. 

John    C.    Neill,   O.D.,    Pennsylvania   College    of  Optometry,   6100 
North   12th   Street,    Philadelphia   41,    Pennsylvania 

J.    William  Oberman,    M.D.,    Pediatric   Consultant,    Division   of 
Health   Services,    U.    S.    Children's    Bureau,    Welfare   Administration, 
HEW  North  Building   4414,   Washington,    D.    C. 

William  Parsons,   Asst.    Chief  for  Program  Development,    Neurological 
and  Sensory   Disease   Service    Program,    Bureau   of   State   Services, 
U.    S.    Department    of  Health,    Education,    and   Welfare,    Washington, 
D.    C.       20201 


Miss  Betsy  Phillips,  Division  for  the  Blind,  Library  of 
Congress,  Washington,  D.  C.   20540 

Maya  Riviere,  D. Phil. ( Oxon. ) ,  Executive  Director,  Rehabilitation 
Codes,  Inc.,  i860  Broadway,  New  York,  New  York    10023 

Vernon  Reese,  O.D.,  4014  Moravia  Road,  Baltimore,  Maryland 

Alfred  A.  Rosenbloom,  O.D. ,  Dean,  Illinois  College  of  Optometry, 
3241  S.  Michigan  Avenue,  Chicago,  Illinois 

Rev.  Otto  C.  Schuetze,  Christ  Lutheran  Church,  8011  Old 
Georgetown  Road,  Bethesda  14,  Maryland 

David  C.  Sharman,  Director,  Washington  Office,  American 
ODtometric  Association,  1026  17th  Avenue,  N.  W. ,  Washington, 
D.  C.    20036 

Louise  L.  Sloan,  Ph.D.,  Wilmer  Institute,  Johns  Hopkins 
University,  Baltimore,  Maryland   21205 

Richard  Snow,  O.D.,  533  Main  Street,  Laconia,  New  Hampshire  03246 

Cmdr.  Donald  Still,  U.  S.  Naval  Hospital,  National  Naval 
Medical  Center,  Bethesda,  Maryland    20014 

Mrs.  Ada  B.  Stough,  Asst.  to  the  Commissioner  on  Aging, 
Administration  on  Aging,  U.  S.  Department  of  Health,  Education, 
and  Welfare,  Washington,  D.  C. 

Lester  H.  Sugarman,  O.D. ,  38  West  Main  Street,  Meriden,  Connecticut 
06450 

Reynold  Swanson,  O.D.,  214  E.  Marks  Street,  Orlando,  Florida 

Noble  J.  Swearingen,  Director.  Washington  Office,  American 
Public  Health  Association,  224  E.  Caoitol  Street,  Washington, 
D.  C.    20003 

Robert  J.  Teare,  Ph.D.,  Senior  Research  Scientist,  Human 
Sciences  Research,  Inc.,  McLean,  Virginia 

Captain  R.  L.  Vasa,  MSC,  USN,  Department  of  the  Navy,  Bureau 
of  Medicine  and  Surgery,  Washington,  D.  C.   20390 

Thomas  Ward,  O.D.,  810  Fleming  Building,  Des  Moines,  Iowa 

Wallace  Watkins,  Director  of  Field  Services,  Goodwill 
Industries  of  America,  1913  N.  Street,  N.W. ,  Washington, 
D.  C.  20036 


vi 


L.    Albert    Webb,    O.D.,    160   Beech  Street,   Holyoke, 
Massachusetts        01040 

C.    Edward  Williams,    O.D.,    612   Emoire    Building,    Denver, 
Colorado        80202 

Russell   C.    Williams,    Chief,    Blind   Rehabilitation, 
Department    of   Medicine    and   Surgery,   Veterans   Administration, 
Washington,    D.    C.  20420 

Miss    Mary   J.    Wintle,    Reference    Department,   Division    for  the 
Blind,    The   Library   of  Congress,    Washington,    D.    C.        20540 

Douglas   Wisman,    O.D. ,    124   South   Main  Street,    Woodstock, 
Virginia        22664 

Hayvis   Woolf,    O.D.,   575    Pontiac   Avenue,    Cranston,    Rhode 
Island  02910 


-i  i 


TABLE    OF    CONTENTS 


il    Mo. 


Title    of   Paoer 


Author 


Page  No 

X 

1 

10 

15 

20 

23 

25 

31 

39 

46 

48 

52 

55 

57 

64 

73 

31 

91 

1 
1 
1 
1 
1 

2 
2 


2 
2 
3 

3 

3 

3 


Fore  ward 

Keynote    Address 

Vocational   Rehabilitation   of   the 
Blind  and   Partially   Sighted 

The    Role    of   Rehabilitation    Codes 

Industry   Views   Visual   Imoairment 

Vision    for  Older  Citizens 

Sheltered  Workshops 

What    the   Adult   Health   Protection 
Act    will   mean   to  Optometry 

Subnormal   Vision    Care:      An 
Analysis    of  Clinic   Patients 

Visual   Asoects   of  Ocular 
Pathologies 

Recent   Advances    in   Low  Vision 
Care 

Visual   Develooment    in   Severely 
Visually   Limited  Children 

Matching  Vision   to  Vocation 

Non-Visual   Reading  Devices 

Looking  Ahead 


Economic   and   Social   Services 
for   the   Visually    Limited 

Medical   Assistance    Programs    of 
the    Bureau   of  Family   Services 

Preventing  Blindness 


Hayvis    Woolf,    O.D. 

V.    Eugene    McCrary,    O.D. 

D.    C.    MacFarland,    Ph.D. 
Maya  Riviere,    D.  Phil.  (Oxon.  ) 
Richard  Feinberg,    Ph.D. 
Mrs.    Ada   B.    Stough 
Wallace   Watkins 

John   E.    Fogarty,    M.C. 

Alfred   A.    Rosenbloom,    O.D. 

Ralph   Gunkel,    O.D. 

Louise    L.    Sloan,    Ph.D. 

Douglas   P.    Wisman,    O.D. 

Earl  T.    Klein 

Eugene  F,  Murphy,  Ph.D. 

Charles  Gallozzi 

Mary  J.  Wintle 

Terence  C.  Carroll 

Sarah  A.  Butts 
William  B.  Parsons 


viii 


h 


1   No. 

Title    of  Paper  . 

Author 

Page   Mo 

3 

Large    Print    Books 

Keith  Jennison 

92 

3 

Community   Services    for  Visually 
Limited   People 

J.    Arthur   Johnson 

94 

4 

Some    Problems    in   Identifying 
the   Visually   Limited 

Hyman   Goldstein,    Ph.D. 

102 

4 

The    Council    for  Exceptional 
Children 

Mrs.    Kate   C.    Kern 

110 

n 

Communications   in   Reaching 
the   Visually   Limited  Worker 

Edmond  J.    Leonard 

116 

*   / 

Decentralizing  Low  Vision   Care 

Edwin   B.    Mehr,    O.D. 

120 

4 

Reaching  and   Serving 
Visually   Limited   Children 

J.    William  Oberman,    M.D. 

125 

1 

Reaching  Our  Visually 
Limited   People 

Caroline   Austin,    M.A. 

129 

5 

Clinical   Optometry   Looks   Ahead 

Morton   Davis,    O.D. 

136 

5 

Programs    of   the    Office    of 
Economic   Opoortunity 

Gertrude    T.    Hunter,    M.D. 

144 

5    y 

Psychology   Looks    at    Low 
Vision    Research 

Robert   J.    Teare,    Ph.D. 

148 

5 

Research,    Development    and 
Evaluation   of  Sensory   Aids 
for  the    Blind 

John   K.    Dupress 

155 

5 

5 

The   Welfare    Administration, 
U.S.    Department   of  Health, 
Education   and  Welfare 

Joseph  Meyers 

163 

Voluntary   Community   Action 

Lee    Holder 

166 

5 

Group  Health   Insurance    Looks 
at   Visual   Limitations 

J.    F.    Pollmann,    Jr. 

173 

i    V 

FOREWORD 


Hayvis  Woolf* 


"Aid   to   the   Visually-Limited"    infers   the   broadest 
possible   horizons    of   concern    for  those    among  us   who,    for 
whatever  reason,    are    suffering  economically   or  socially 
from  a   visual   limitation.      The   problems    of   identifying  and 
serving   these   people    involve    a   vast   comolex   of  services 
which,    at   this   Conference,    have   been   brought   to   a   common 
point    to   Dlan    for  their   future    welfare. 

Education   of   the    ootometric   profession    to  the    vast 
challenge    was   the   primary   objective    of  the    conference.      The 
extent    to   which    this    goal   was    achieved   can,    in  oart    at    least, 
be    .judged   from  the    list   of   governmental   and   of  private 
agencies   participating  in   the    sessions.      The   enthusiasm  and 
competence   with   which   these   particioants    addressed  them- 
selves  to   the   task    at   hand   demonstrated  the    depth   of  their 
concern.      To   see    that   that   exoression    of   concern   shall 
have    fallen   on    fertile    ground   is    the    current    responsibility 
of   the   profession    of   optometry   and   is    the    objective    to  which 
the   publication   of  these    "Proceedings"    is    immediately 
directed. 

From   our  youngest   to   our   oldest,   existence    in  a  world 
unnecessarily   visually-limited   is    unjust   and    socially,   as 
well    as   economically,    deplorable.      Every  effort   must   be 
brought,    as   promotly   as   oossible,    to   the    maximum  reduction 
of  these    limitations.      This    Conference    afforded  the   platform 
upon   which    forward  action    into   these    areas    of   resoonsibility 
can   be,    and  must   be,    based. 

5  75    Pontiac   Avenue 

Cranston,    Rhode    Island     02910 


*0.D. ,    Chairman ,    Committee    on    Administrative    Agencies, 
American    Ootometric    Association 


CONFERENCE    SCHEDULE 
THURSDAY,    MARCH    24,    1966 

8:30   a.m.    -   Registration 

9:15    a.m.    -   Invocation   -  The    Reverend   Otto   Schuetze 

Christ    Lutheran   Church,    Bethesda,    Maryland 

9:20  a.m.  -  Welcome  -  Henry  J.  Hoff,  O.D.,  President, 
The  Optometric  Society  of  the  District 
of  Columbia 

9:25    a.m.    -  Keynote   Address    -  V.    Eugene   McCrary,    O.D., 

President,    American   Optometric  Association 

10:00    a.m.    -  Panel   1:    "Identifying  our  Visually-Limited 

People" 

12:15   p.m.    -  Conference    Luncheon.    Chinese    Room  of  the 

Mayflower  Hotel.      Guest    Speaker:      The 
Honorable   John   E.    Fogarty,    Congressman 
from  Rhode    Island 

2:00   p.m.    -   Panel  2:      "Serving  the    Visual   Needs   of  our 
Visually-Limited   People" 

4:45   p.m.    -   Recess    for  dinner 

7:00  p.m.    -   Panel   3:      "Serving  the   Social  and  Economic 
Needs    of  our  Visually-Limited   People" 

9:30   p.m.    -  Adjournment 

FRIDAY,    MARCH    25,    1966 

9:00   a.m.    -   Panel   4:      "Reaching  our  Visually-Limited  People" 

11:45    a.m.    -   Recess    for   lunch 

1:15   p.m.    -  Panel  5:      "Planning  for  the   Future" 

3:45   p.m.    -    Conference    Summary 

4:00   p.m.    -   Adjournment   sine    die 

****** 

Each  panel   session   opened  with   several   brief  papers. 
The    audience    then  broke    into   small   discussion   groups.      The 
panelists   then   returned  to   receive   questions    from  the    discussion 
groups. 


xi 


The    Conference    Committee    wishes   to  acknowledge   the 
following   organizations    and   institutions  which   were 
represented   by   observers   at    the    Conference: 

Chicago    Lighthouse    for  the    Blind 

Industrial   Home    for  the    Blind    (Brooklyn) 

National   Federation    of  the    Blind 

National   Society   for  the    Prevention   of  Blindness 

U.    S.    Army 

U.    S.    Navy 

U.    S.    Air   Force 

American   Public   Health   Association 

National   Institutes    of  Health,   Visual   Sciences 
Study   Section 

Sinai    Hospital    of  Detroit 

Library  Services   Branch,    U.    S.    Office    of  Education 

The    above    groups    are    in   addition  to  those    groups 
represented  by   panel  participants   as    identified   in   various 
portions   of  these    Proceedings, 


xil 


KEYMQT5    ADDRESS 
V.    Eugene    McCrary* 

First    of  all,    I   extend   to   the   oarticioants   of  this 
conference   the    official    greetings    of   the    Officers    and 
Board   of  Trustees    of   the    American   ODtometric    Association. 
We    are    very  proud   to   be    able    to  Dlay   a   role    in  this 
conference,    in   what   we    feel   will   be    a   very   worth-while 
endeavor.      I   want    to   soeak   with   you   for  ,just    a   few  moments 
today    about   the    new   challenges    facing  the   profession   of 
optometry. 

Assembled   in   this    room  are    a   large   number  of   important 
people— key    figures   in  the    common  war  against   the   waste    of 
human   resources    due   to   vision   imoairment.      We   are    all 
dedicated  to  the   prooosition   that   everyone    in   our   great 
nation   should  have    the    ooportunity   to   attain    full 
stature — socially,   emotionally,    intellectually,    and 
economically — as    an   individual   member  of   society. 

This   has   been   called  a    "Conference    on   Aid   to  the   Visually- 
Limited".       If  it    had  been  held   a    few   years    ago,    it   might    well 
have   been   called   a   "Conference    on   Vision   Aid   to   the    Partially- 
Blind".      The    differences    between   these   two   titles   eoitomize 
the    objectives    of  this    conference    and  are    well   worth   analyzing 
in    some    detail. 

Not   too   many   years   ago,    the    American   Optometric   Association 
officially   recognized   a  basic   change    in   viewooint   by   adopting 
the    term  "partially-sighted"    to   replace    "partially-blind". 
Today   we    are    focusing  our  thoughts    and  actions   on   ability 
rather  than   disability.      Our   special   challenge    in   vision 
care,    in   working  with   patients   with   visual   impairments,    is 
to   assist   them  by  every  means  oossible    to   achieve    independent 
social   and  economic   status   in   our  visually-centered   society. 

The   profession   of   optometry,   in   the    United   States,    cares 
for   approximately   seventy-five   percent    of  the    visual  needs 
of   the   Dublic.      In   that   care   there    are    involved   several   basic, 
unique    concepts.      In   a   clinical    sequence    which   includes   case 
history,   examination    for  pathology    (external   and   internal), 


*0.D.  ,    President,    American   Optometric   Association 


refraction  (visual  acuity  Rx) ,  visual  analysis,  and  final 
disposition,  the  optometrist  conducts  his  examination  with- 
out the  use  of  "drops"  in  the  patient's  eyes.  Dynamic  vision, 
with  the  two  eyes  working  together,  cannot  be  examined  in  that 
state.  In  fact,  no  evaluation  of  nearpoint  vision  can  be  made 
while  the  focusing  mechanism  is  under  the  paralyzing  influence 
of  drugs. 

The   examination    for  pathology   is    an  early    and   integral 
part    of  an    optometric   examination.      In   his   never-ending  search 
for   signs   of  pathology,    the    ootometrist   utilizes    clues    from 
the   case   history,    direct    observations,    ophthalmoscooy ,    ocular 
mobility  tests,    ophthalmometry,    Schiotz   scleral  tonometry   and 
electronic   tonometry,   visual    fields    (perimetry,    tangent    screen, 
and   campimetry)    biomicroscopy    (slit    lamp),    and   other   instruments. 

In    the    textbook   The  ..Optometrist '  s_  Handbook  _of  Eye    Diseases, 
by   Joseph   I.    Pascal,    M.  D.    and  Harold   G.    Moyes,    M.D.  ,   printed  by 
C.V.    Mosby   Company,    the    authors   state    in   the   preface: 

"The    importance    of  the    subject   can   be   appreciated   from  the 
fact    that    the    optometrist    in  the    course    of  his   professional   work 
is   bound  to  come    in   contact    with   eyes   which  may   be    diseased.      In 
fact,   he    maybe    the    first   to  come    across    diseases   of  the   eye   which, 
because    of  their  unobtrusive   nature,    that    is,    lack    of  startling 
objective    or   subjective    symptoms,    may   send  the   patient   to   the 
optometrist    first,    for  example    glaucoma   simplex   or  diabetic 
retinopathy.      Sometimes   the   eyes   he    sees   may   be    in   a   stage 
of  active    inflammation,    or  they   may   present    the    sequelae    of 
some   previous    disease    which   has    already   run   its   course. 

"Thus,   the    optometrist    is    sometimes   the    most    important 
member  of   the   healing  professions   with    regard  to   the   patient 
getting  the    quickest   medical   or  surgical   service.      To  perform 
this    service    successfully  he    need   only  know,    sometimes   merely 
suspect,   pathological   deviations    from  the    normal.      This   is   his 
principal   concern.      Of   course   he    must   also   be    sufficiently 
familiar  with   the   Physiological   deviations    from  the   normal   so 
as   to  know  when  a   referral   to   the   medical  practitioner  is   nec- 
essary  and  when    it   is   not.      Differential    (pathological)    diagnosis 
is    a   large    and   difficult    field.      A  medical   specialist   with   all 
his    training  in  this    direction,   with   many    facilities    for  making 
all  kinds   of   auxiliary   tests,    is    sometimes   unable    to  make    a 
differential   diagnosis.      What    good   is    it    for   the    optometrist 
to   involve   himself  in   such   work?" 

The    authors   also   state    on  page   nineteen,    under  the   head- 
ing "The    Optometrist    in   Relation   to  Sye    Diseases": 


"In    any    survey    of   the    care    of   the   eyes   in   civilized 
communities    it   will   be    found   that    the    great    majority   of 
citizens    depend   for  the    relief   of   their  common   visual   dis- 
turbances   on   refracting   ooticians,    ophthalmic    opticians, 
and,    in    America,    optometrists.       This    means    that    the    first 
line    in   detecting  early   disease   processes    and   frequently   in 
preventing  blindness    is    held  by   these   oractitioners.      Hence, 
the    great    importance    of   learning  to   detect    signs   which   point 
to   derangements    of   the   eyes    or  to   the   body   in   general." 

It   is    out    of   this    general   background  that    we   have 
evolved  the    statement   that    "Ootometry    represents    the 
first    line    of   defense    against   blindness    in    the    United 
States   today." 

Next,    I   stress    the    significant    increase    in   the    variety 
of  technical   materials   and   instruments    available    to   us.      I 
shall  not    dwell   on   this   phase    of  the   tooic   as   it    shall   un- 
doubtedly   come    into   consideration   this    afternoon    in   Session 
Number   Two.       However,    I    do   urge    all    of  you   to    look    over  the 
demonstration    of   low  vision    aids   orovided   for  your   information 
outside    the   entrance    doors.      New  materials    and  new  techniques 
of  processing  have    been   key   elements   in   this    development. 

Optometrists    have    been    largely    responsible    for  the 
development    of   ootical   devices    for  the   partially   sighted. 
Our  interest  began    years    ago   in   the    infancy    of  this   ohase, 
and  we   are    continuing  to   add  even   more    to   the    fund  of 
knowledge    in   this    field. 

I   wish  to  oay   tribute    to   the    multitude    of   optometrists 
today   who,    across    the    land,    are   oroviding  assistance   to    low 
vision   patients   in   their   offices    and   to  the    ootometric 
consultants   in    low   vision   clinics   working  as   members    of 
inter-disciplinary   teams. 

The    second   factor  in   the    growth    of   our  abilities   to   help 
these   people    as   never  before    is    our  burgeoning  knowledge    of 
the   nature    of   vision    itself — its   keener  insights    into  the 
develooment    and  the    function    of   vision.      This    topic   will   be 
the    special   concern    of   one    of   the   paoers   on   Panel   dumber 
Two — the    one    by   Dr.    Wisman — but    I    cannot   resist    adding   a 
few  words    of  emohasis    at    this    ooint.      Low  vision    devices 
are    available    to   all   who   are    legally   qualified  to  orescribe 
them — in   fact,    many   of   the    aids   which   you  can   see    in   the 
other   room   are    "over-the-counter"    items,    available    to   any- 
one,   without   prescriotion.       What    the    profession    of   ootometry 
brings,    uniquely,    to   the    low   vision   situation    is   not   a   set 
of  devices   or   a  mechanical   set    of  "fitting  Drocedures",    but 
rather  a  point   of  view;    if  you  will,    a  dynamic,    holistic 
philosoDhy   of  vision    care.      We    are    convinced  that    a   segmented 


aooro^ch   is   oitifully   inadequate.      I   urge   your   careful 
consideration    of   this    holistic    asoect    of   Dr.    Wisman's 
material. 

We    in    ootometry   have    been    and   must    continue    to    do   an 
even   better  .1  ob    of   utilizing   all    of   our  talents    so   as    to 
render  the    finest    of   care    to  each    and  every   oatient    to 
assist   him   to    reach   his    highest   social    and  economic 
potential   by    functioning   to  the   maximum   caoacity    of  his 
visual   abilities. 

Historically,    ootometry,    through    the    use    of   ootical 
devices,   has    aided  oatients    from   a  mechanistic   Doint    of  viewj 
however,  the    modern   aooroach   of   more    recent   years    is   to   con- 
sider the   whole   oerson.      We    must    deal   with  the    factor  of  the 
dignity   and  unity   of  man   and   teach   the    skills   necessary   to 
achievement   of  the   maximum   degree    of   rehabilitation   possible. 

Akin   to  this   emohasis    on   vision    as    a   trainable    skill, 
is   the    attitude    of   ootometry  toward  the   oarticular  Droblem 
of  each   individual  Datient.      No    longer   can   we    limit   our 
horizons   to   "vision"    aids.      We   must   be  oreoared  to   assist 
our  oatients   Tn    any    direction    in   which  thev   need   assistance. 
Thus   we    talk   in   terms   of  "aid",   with  no   qualifying  adjectives. 

To  the   modern   ootometrist,    academically   strong   in  the 
areas   of  behavioral   science    as    a  result   or  emohasis   in   this 
direction    in   our  orofessional   schools    (which   emohasis    is 
undoubtedly   destined  to   increase    as    all    of   our  educational 
orograms    become    six   years   in    length)    vision    is   viewed,   not 
as    an   innate,    automatic,   orimarily   ODtical,    "reflex",   but 
rather   as    an    asoect — albeit    a   dominating   one — of  the   total 
behavior  of   a  oerson    ooerating   in   a   soecific   environment. 
This    ootometrist    aooroaches   his   professional   task    from  the 
ooint    of  view  that   vision    is    a  trainable    skill — as    amenable 
to  training  as   is    soeech   or  the    learning   of  the   multiplication 
table — and  that    any   mechanical   or   ootical   aids   utilized   in 
that    teaching  orocess    are    only   incidental   to  the    larger 
"picture".      Aids    are    only   the    means    to   a    larger  end. 

Many   of  these    visually   limited  persons   have   been   and 
are    today   on    our  blind  oension    roles,    in   our  schools    for 
the   blind   and   in   soecial   classes    in   our   school    systems. 
Many   are    unemployed  because    they   have   not   had   the    opoortunlty 
or   advantage    of   a    low  vision   examination   by   an    optometrist 
with-  aporooriate   corrective    measures    instituted.      Instances 
are   too   frequently  turning  uo    of  oersons   who  have   been  en- 
rolled or   cared    for   as   a   blind  oerson   but   who,    after 
comoetent   ootometric   care,    return   to  orimary   deoendence 
uoon   visual   clues.      ^or  example:      a  student    in   a   school 
for  the   blind   for  eleven   years    is   now  able    to   read  Jaeger 
two   size   tyoe    and   goes   to   college,    doing  his    own   reading; 


a    child    failing   in   school    in    sixth    grade    is    assisted   with 
devices    that   eliminate   personal    reader  and  he    goes    on    to 
graduate;    an   adult    breadwinner,    unemoloyed   for   four  years 
due    to   visual   limitations   is    able    to   return    to   his    original 
.1  ob    and   become    a    supervisor   after   receiving   ootometric    care. 
Social   and  economic    aid  was    achieved,    minimizing  the    debili- 
tating effects    of   the    original    condition    by    comoetent    ootometric 
care.       Unquestionably,    a   number   of   the    social    and  economic 
Droblems    of   the    Dartially   sighted    can    be    eliminated    or 
minimized    through    oatients    having   the    opoort  unity    of   re- 
ceiving orofessional    ootometric   care.      Thus,   we    feel   that 
admission   to   a    school    for   the    blind    or  sight    saving    class 
should  have    as    a    requirement    a   orior  examination   by    one    skilled 
in    the   examination    of  the   oartially    sighted — a   functionally 
oriented   soecialist. 

On    the    other  hand,    ootometry    needs    to    know   the   extent 
and   availability   of   other  services    on   national,    state   and 
local    levels.      We    solicit    the    oarticioants    at   this    conference 
to   assist   our  profession    in  establishing  ties    of  coooeration 
with   your  agency   and   services.      We   must    search   together   for 
the    answer  to   this    question — "How   can   we   best   serve   the 
visually    limited  peoole    of  this   nation    to   achieve   the 
maximum  utilization   of  their  human   DOtential"? 

We    in   ootometry   need  to   deeoen   our  understanding   of  the 
varieties    of  help   that   are   available,    both    social   and  economic, 
to   the    visually   limited.      Visual   rehabilitation    is    an  extremely 
imoortant    objective    in   the   work    the    ootometrist    does   today. 
While    total    rehabilitation  embraces    a  soectrum   of   services, 
visual   rehabilitation    is    one    of   the    fundamental   steps    on   the 
road  toward   larger   goals. 

Because    it    is    only   a  part    of  the   picture,   we    must    factor 
in   the    total  oerson — socially,    intellectually,   osychologically 
and  economically — as   well   as    visually.      This    is   why   we    feel    so 
strongly    today   that    it    is    the   team  aporoach   which    offers   the 
best    answers,    the   most  hope    for  the    future    in  working  with   the 
visually    limited. 

The   emohasis   of  this    Conference    is    heavily   in  this    direc- 
tion.     With   a   generosity   of  their  time    and  knowledge,    far  and 
above    and  beyond   "the    call    of  duty",   we    shall  have   with   us 
during  these   two   days   of  this    Conference,    a  half-hundred  ex- 
oerts  who  are    soecialists    in   the    social   and  economic    asoects 
of  rehabilitation.      We   have    gathered   this    team  at    this    confer- 
ence,   to   learn   all   we    can    from  them  in  this   short   time,    to  the 
end  that  we,    the    optometric  profession,    might    gather  new   under- 
standing  and  thereby   bring  new    light   and  hone    into   the    lives    of 
our  patients. 


We   want   to    learn   how  better   to   integrate    our  professional 
services    with    the    services    of   other  orofessionals   who   will  be 
working  with   our  oatients ,    so  as   to  enable   us   to   do   a  better 
.job   of  referral.      In   terms    of  the    specific   patient,   we   want   to 
be   able   to   offer  him  sound  advice    and   guidance    on   how  to 
establish   contact   with    all   available    social   and  economic 
resources   so   as    to  bring  himself,    with   our  assistance,    into 
the    fullness   of   a    socially   and  economically   integrated   life. 
We    are   eager   to    learn    more    about    the    role    to   be   olayed  by 
each   team   member. 

It   might   clarify   my    Doint    a  bit    to   observe    that,   at 
the    moment,    and    for  a   certain    segment    of  the   oooulation, 
services    of   the    tyoe    to   which    I    refer  here,    already  exist. 
Throughout    the    length   and   breadth    of   our   land   there    are 
organized,   efficient,    knowledgeable    agencies — both  oublic 
and  private --whose    sole    objective    is    to   serve    the   oeoole 
of   our  nation   who  are    visually    limited  enough   to   be    labeled 
"legally   blind".       In    the    vast    majority    of   our   states,    it    is 
necessary   only   to  establish   contact    between   the   oatient    and 
his    state's    agency    for  the   blind,    and   integration    oroblems 
are    immediately    in   skilled,   exoerienced  hands. 

This    same    level   of   organization — in   social   and   economic 
rehabilitative    services  —  is    WOT    available    for  those   who   are 
visually    limited,    but   not    enough    limited   so   as   to   qualify 
for   assistance    as   "legally   blind".      This    large    grouo    of 
oeoole--who  have    been    called   "the    forgotten   oeoole"--is 
presumably   much    larger  than  the    group    of   the    legally-blind 
(note   that   we    do  not  even   have    a    firm   study   of  how  many 
there    are    in   this    grouo,    let    alone    any   definitive   work   as 
to   their  soecial  needs)    yet    they    are    largely  without    soecial 
resources.      They   have    many    of  the   oroblems    of  the    legally 
blind.      They    cannot    be    licensed   to   operate   motor  vehicles; 
they   can't   read   many    of   the    commonest    sources    of  the   orinted 
work;   they    can't    begin   to   cope    with    the    visual   demands    of 
many,    many   jobs    in    our   increasingly   visually-centered 
commerce   and    industry.      Yet    there    is   no   source    of   organized, 
knowledgeable    guidance    for  these   people    as   they   seek   their 
goal   of   living   a    full,   meaningful  productive    life. 

It    is    our  hoDe    that   ootometry,    as   the   profession    initially 
involved   in   bringing  these   oeoole    to   the   maximum  of   their  visual 
performances,    may   also  become    more   oroficient    in   counseling  them 
thoroughly   and   wisely   on   the    larger  aspects    of   their  problem. 
We    sincerely   hope    that    one    of  the    results   of  this    Conference    will 
be   a   significantly   increased  ability   on   the   part    of   our  profession 
to   discharge    this   enlarged   responsibility. 


Two   points    are    left — which    I   would   like    to   stress.      The 
first    stems    from  the    fact    that,   particularly   because    of  their 
economic    situation,   a   significant   proportion    of   these   oeoole 
do  not   have    financial   resources   available    to  them  to   meet 
the    costs   of  this   kind  of   optometric    care.      Optometry   stands 
ready  to   work   coooeratively  with   social   and   welfare    agencies 
in   searching;   for  more   effective    ways    to  cooe   with   this   oroblem. 
The    cost    of   this   care    is    really    a   resoonsibility    of  the   oeoole 
of   the    United  States.      Furthermore,    it   is   essential   to   realize 
that,    in   the    larger   sense,    such   programs   are    fundament allv   self- 
sustaining;.      The   oeoole   who   are   not   sociallv    and  economically 
indeoendent    as   a   consequence    of  visual    limitations    are   being 
maintained  today    by   one    or  more    forms    of  oublic    assistance. 
It   is    our  desire   to  helo   them  become    contributing  members   of 
society,    with  the    realization   that    the   cost    of   this   helo   is 
far   less   than   the   cost    of  continuing   to   suooort    them  in    their 
non-Droductive ,    deoendent    role. 

Optometry   wants   suggestions   and   guidance    in   this    asoect 
of  the   oroblem.      There    are    many  things   we    should  know   and  we 
desire    to  become    more   knowledgeable    so   as    better  to   be   able 
to   do   our  part    in  bringing  these   oeoole    into  economic    orod- 
uctivity,    or  at    least   into    full   stature    as    socially   indeoendent 
individuals.      We   seek    answers   to    such   questions    as:      How   can 
the    costs    of   such    rehabilitative   activities  —  (and  as    you  know 
their  per  caDita  demand   in    terms    of  hours   is    very   high) — be 
met?      Are   Dublically-suooorted   vision    care    clinics   oart   of 
the    answer?      We   turn   to  you,    our   guests   and   mentors    at    this 
Conference,    for   suggestions   and   guidance. 

Optometry   reaffirms    its    desire    and    feels   its    resoonsibility 
to  orovide    visual   care    to   all   of  the   oeoole,    and  not   to   just 
most    of   the   Deople.      We    are   not  now  adequately   meeting  this 
need;    we   need   to   learn   how  to   do   it.      We   need  assistance    in 
more   efficiently   organizing  and   distributing  vision   care.      We 
are   oreoared   to   admit    that    our  traditional    form  of  private, 
individual  oractice    is    in   many   ways   insufficient    and    inadequate 
to   meet   the    growing  visual  needs    of  the    American  public.      We 
seek   more   effective    ways    of  discharging   our  oublic    resoonsibility 
for  the    visual    ca^e    of   the   oeoole    of   the   United   States    of   America. 

Ootometry   is    raoidly   moving  to  exoand  her  orofessional 
horizons — to  make    them  more    comoatible   with    1966*  s    social   con- 
science.     We    look    forward  to   the    day  when  no   one    shall   suffer 
from   lack   of    full   optometric    care    due   to    financial,    or  any 
other,    reasons.      May   we   then   dedicate   this    Conference   to 
ootometry' s    resolve   that   every   man,    woman   and   child   of   our 


nation   who,   because    of   visual    limitations,    is    imoeded 
socially,   economically,    developmentally ,   or  academically, 
be    given   the    oooortunity   to  have   his   oroblems   solved  and 
thereby,   be    able   to    live    a  haooier,    more   oroductive    life 
with    dignity    and    indeoendence.       Ootometry,    and   those    of 
you,    our   friends   who  are   oarticioat ins;  in   this    Conference, 
can    seek    no   higher   goal. 


4500   Beechwood   Road 

College    Park,    Maryland     207^0 


PANEL    I 

"Identifying  Our   Vlsuallv-Limited    People" 

Morning   Session,    March   24,    1966 

Panel    Chairman    -    CHARLES    MARGACH,    O.D., 
Director,    Low   Vision   Clinic,    College    of   Ootometry, 

Pacific    University 

****** 

PAPERS    PRESENTED   BY 

D.    C.    MacFarland,    Ph.D.,    Chief,    Division   of 

Services   to  the   Blind, 
Vocational   Rehabilitation 
Administration,    U.    S.    Deoart- 
ment   of  Health,   Education   and 
Welfare. 

Maya  Riviere,      D.    Phil.  (Oxon.  ) ,    Executive    Director, 

Rehabilitation    Codes,    Inc., 
Princioal   Investigator,    Classifi- 
cation  of   Imoairment   of  Visual 
Function    -  NB-05398 

Richard   Feinberg,   Ph.D.,    Chief,    Visual   and   Auditory 

Laboratory,    Georgetown   Clinical 
Research   Institute,    Federal 
Aviation    Agency. 

RESOURCE    PANELISTS 

Mrs.    Ada  Barnett   Stough,    Assistant    to  the    Commissioner 

on   Aging,    Administration    on    Aging, 
U.    S.    Deoartment    of  Health,   Education 
and  Welfare. 

'Wallace   Watkins,      Director  of   Field   Services, 

Goodwill   Industries    of   America. 


VOCATIONAL    REHABILITATION! 
OF   THE 
3LIND    AND   PARTTALLY    SIGHTED 


D.    C.    Mac^arland* 


In    1965   more    th=m    13,000   blind  and  oartially   sighted 
individuals    were    rehabilitated  into  employment    through   our 
State-Federal   orograms — 5,^50   of  these    were    within   the    lep-al 
definition    of  blindness,    that    is,    havinp;   better   than   20/200 
vision    with    the    best    correction    but    still    suffering    from   a 
serious    visual   handicap.      When    we    consider  the    number   of 
oersons   who  have   been   served  through   the    State-Federal 
Vocational   Rehabilitation    Program,   trained   and  placed   in 
emoloyment,    and   suffering   from  disabilities   in   addition 
to   serious    visual   handicaos   but    codified   under   a   different 
category,    we    can   make    a   conservative   estimate   that   aooroxi- 
mately   20,000    of   our  total  number  of   rehabilitations   had 
severe    visual    limitations. 

It   would  be   virtually   imoossible   to  enumerate   even   a 
small    fraction    of  the    variety   of  /jobs   that   are   now  being 
successfully   Derformed  by   oersons   with    seriously   imoaired 
vision.      It   has   been   conservatively  estimated   that    there 
are    some    30,000    different    jobs    at   oresent   being  Derformed 
by  persons  within   the    legal   definition    of   blindness;    jobs 
ranging  from  kitchen   workers   to    college   professors    and  just 
about  everything  in   between.      There    is    a   direct   correlation 
between   the    amount    of  vision   and   the   number   of   job   odd ort unities, 
So,   you   can   see   that    with   the    increase    in  partial   vision,    job 
opportunities   become    almost    limitless. 

At   this    outset,    let    me    state    that    we   do  not    believe   that 
13,000   or  20,000   or   30,000  by   any   means    reoresent  the   maximum 
number  of  persons   who    could  be   and   should  be    receiving  services 
from  our  State-Federal   vocational   rehabilitation   agencies.      We 
do   feel,   however,    that   the   extensive   prevention   work   which   is 
now  being   carried   on,   oarticularly   in   the    agencies    for  the 
blind  and   visually  handicapped,    is    contributing  mightily   in 
reducing  the   number   of   severe    cases   which   reach   our  rolls 
each   year.      For  examole,    a   few  months   ago   I   had   occasion   to 
review  the   orogram   of   one    of  the    smaller  Southern   States. 


*Ph.  D.  ,    Chief,    Division   of   Services   to  the    Blind,   Vocational 
Rehabilitation   Administration,    U.    S.    Deoartment    of  Health, 
Education   and  Welfare 


10 


The    agency    had  a  prevention   of  blindness   Drogram  which   had 
served   in   1965    over  5,000  persons.      It   was    operating  with 
a   small   approDriation   and   with   an    increased  allotment    could 
easily   orovide    services   to   almost   twice   that   many.      I   think 
it    is    safe    to   assume    that    where    individuals    receive    early 
medical   care,    eye    surgery,    and  proper   fitting  of    lenses 
through   our  orevention    of   blindness    departments,    many 
never  reach   the   point    where    rehabilitative    services    are 
necessary. 

In   the    foregoing   statements,    I    hope    no   one    will    infer 
that   we   believe   blindness   and  handicapping   conditions    are 
on   the    decrease,    for  you   and   I    know   that    this    is   not    true. 
Through   research   and  better  understanding   of   the   problems, 
we   are    able    to   helo   many    thousands    live    normal   and  oroductive 
lives,    but   there    is    a   long  way   to   go.      We    in    rehabilitation 
are    the    first  to   recognize    this.      We   have    only   to   remember 
the    ootimistic   view  that    all   of  us   took   when   the    break- 
through  on    retrolental    fibroolasia  was    announced   and   it   was 
found   that    in    most    instances    it    could   be    brought    under 
control.      However,    during   the    six   or  seven-year  period   when 
oxygen   was    fed   indiscriminately   to   children,    some    15,000 
were    blinded   and   often   left   with   additional   disabling 
conditions.      We   were    very  proud   of   our  modern   technological 
advances    and   rightly    so.      We    discovered   over-oxygenation 
was   the    cause    and  that    in   over   90   oercent    of   the    cases   this 
could   be   prevented.      Mow,    10   years    later,    and   in    SDite    of 
great    scientific    strides   which   have    been   made   by   all 
orofessions   within   our  nation,   we    are    again    faced   with   a 
situation   which   will,   no   doubt,    leave   thousands    of   children 
blind   and   suffering   from  multi-handicapping  conditions.      It 
was   brought   to   my    attention   a   few  weeks    ago   that    we   now 
have    a   wave    of  rubella   sweeoing  the    country    which   can  have 
serious  effect    on    a  newborn    child   if  it    is    contracted   by 
the   mother  in  her  third  month   of  pregnancy.      According   to 
the    figures   quoted  to  me,    there    are    roughly   30,000    children 
who  have    suffered   mild  to   severe    damage    from   this    disease 
alone    in   the   past   year.      Educators    and   rehabilitation 
oersonnel   certainly   have   their  work   cut    out    for  them 
during   the    next    decade. 

A   great    deal   of   social   legislation   was  oassed   during 
the    last    session   of   Congress,   among  which   was   P.L.    89-333, 
the    most    significant   niece    of   legislation    in  the    field  of 
vocational   rehabilitation    since    its   inceotion    some    46   years 
ago.      Our  new  vocational   rehabilitation   amendments    of   1965 
will    make    it   possible   to  provide   extensive    services   to   the 
very   severely   disabled,    services    that    were   heretofore 
impossible    under  the    old   Act,    double    the    number   of  persons 
rehabilitated   into  emoloyment    within   the   next    five   years, 
and   increase    the    quality    of  job   opportunities    available 
to   our   clientele.      For  example,   oreviously  we    were    able   to 
give    only    comparatively   short  periods    of   diagnostic  evaluation. 

11 


Under  the   new    Act,    any   oerson   applying   for  vocational 
rehabilitation   services    can  be    given  a   diagnostic  evaluation 
extending   over  a  oeriod   of  six   months.      For  certain   categories 
of  disabilities,    such   as    mental    retardation,    blindness,    deaf- 
ness,   and   others   designated  by   the    Secretary,    the   oeriod  of 
diagnostic  evaluation   can   be  extended   to   eighteen    months. 
This   will   certainly   have    a  profound  effect   on   what   we    can 
do    for  the    multi-handicapoed  individual.      For  any   one    suffering 
from  multi-handicaooing  conditions    over  a   long  oeriod  of  time, 
it    is   oossible    to   oredict   vocational   success   only   if  highly 
Drofessionally-trained  personnel   have    an   adequate    oDoortunity 
to  evaluate    the    individual's   ootentials   and   to   build  up   his 
own  enthusiasm  and  ego    so  he    can   accept   and  orofit    by   train- 
ing which   will   lead  to    the   ultimate    goal   of  self-supoort . 

The    Act    also   provides    for  Federal   financial  particioation 
in   the    construction   of  workshops    and   rehabilitation    facilities 
which   are    so  necessary    for  working  with   the   multi-handicaooed 
person.      Along  with   the    construction   of  workshops,    Congress 
has    taken   into    consideration   the   necessity    for  long  oeriods 
of  training   for  some    of   the    more    severely   disabled   clients. 
These    individuals    can    remain   in   training  up   to   two   years 
with   liberal  weekly   stioends.      The    ultimate    goal  here    is   not 
typically    for  continuous   employment    in   a  workshoo.      For  some, 
this    may   be    their  maximum  potential.      However,    for  many   the 
workshop   will   merely   be    an    interim  phase    of  employment,    a 
step   in   their  total   rehabilitation    leading  to   gainful  emoloy- 
ment    in  outside    competitive    industry.      Shoos   which  need 
assistance    in   tooling  up    for  the    larger  projects   which    they 
must   undertake    are   being  given   support   in   acquiring  qualified 
oersonnel   and  new   machinery   that   will  permit    them  to  exoand 
their  activities. 

There    are    many  other  provisions    of   the   Act  which   are 
most    interesting  and   will   be   beneficial  to   all   disabled 
persons    in   the    country:      innovation   and  expansion   grants 
to  extend  and   improve    services   in   the    States;    reader 
services   to   the   blind   and   interoretive    services    to  the   deaf; 
a   commission   on   architectural   barriers;    and   Federal   matching 
money   for  supervision   and  management    of  the   Randolph-Sheppard 
Vending  Stand  Program  and   small   business   enterprises    for  the 
severely  disabled.      Also,    a  waiver  of   "state-wideness"   permits 
certain   areas   of   a   state,    in  need   of  greater  vocational 
rehabilitation   services,   to   obtain  these   services    through 
local   support   which   can   be    matched  by   the   state   with  Federal 
funds. 


12 


The    three  most   imoortant    asDects   of  the   bill   are: 

1.  Substantial   increases   in    funds   to   the   State 
agencies,    almost   doubling  the   money   oreviously 
available. 

2.  A   much   more    liberal    Federal   matching  base.      We 
are    currently    ODeratinp;  on   a    formula  which 
ranges    from  50   to    70   percent   Federal   matching. 
Beginning   July    1,    1966,    the    Federal   share    will 

be    75   Dercent    of  total    costs   throughout    the   Nation. 

3.  The    most    far  reaching  orovision,   oerhaos,    is 
the    funding  of  state-wide   olanning.      Under  this 
portion    of  the    Act,    each   state    will   be    given  up 
to   $100,000   per  year   for  a  2-year  period   to 
conduct    state-wide   planning,    studv   the   needs 

of  all  handicaooed  persons  within   the    state's 
jurisdiction,    and  develop    comorehensive   oro- 
grams   to   deal  with   these   needs. 

I   would  be    remiss    in  discussing  our  new  amendments   if 
I    did  not   mention   the    action   taken   to   liberalize    all  phases 
of  our  training   and   research   orograms.      Money    for  workshoDS , 
rehabilitation    centers,    direct    client    services,    diagnostic 
evaluation,    and   all   the    other  phases   of  the   program  which 
have   previously   been   mentioned   would  not    make    it  oossible 
to   do   the    job   unless   we,    in   our  state-Federal   oartnershio, 
carry   out    our  resDonsibility    to   the    states   in   oroviding 
training  programs   to  helo   them  obtain   the   orofessional 
personnel  necessary   to    do   the    gigantic   task  that    faces 
them  during  the   next    decade.      Professional  personnel  needed 
to  do  the    complex   rehabilitation   job   must   come    from  innumer- 
able   disciolines,    and  we   are   endeavoring  to   step   uo   our 
training  programs    considerably   in   order  to  help   meet    the 
current   desoerate    shortage. 

P.    L.    565    p;ave    us    the    authority   to    develop   training; 
programs    and   to   design   and  suooort   research    conducted  by 
universities   and  nonprofit   organizations.      Many   of  you   are 
familiar  with    some    of  the    results   of  these   programs.      Time 
does   not  oermit    me    to   give   you   a  thorough   account    of  some 
of  the   most    important    findings.      These,   however,    can   be 
obtained   from  a   review   of   our   research   and  training 
programs   which  have   been   concisely   outlined   and  summarized 
in   BLINDNESS,   the    Annual   of   the    American   Association   of 
Workers    for  the    Blind,    1964   and   1965.      We   would   recommend 
that   you   review  these   projects.      We   think   you  will    find 
them  interesting;.      We    are   pleased  to   note    that   some    of   the 
research  has   been    conducted  under  your  ausDices   with   your 
supoort   and   good    counsel. 


13 


The    comorehensive   and  most   satisfying  .1  ob    of 
rehabilitation   is    the    responsibility   of   all  of  us.      In 
fact,    it    is   the    summation   of  the   essence    of  the   best    in 
American  ohilosoohy.      No    one    agency,    public   or  orivate,    can 
do   the    total   .1  ob   or,    indeed,    a   substantial    section    of  it, 
without   the    total   suooort   of   all   organizations    and   srouos 
which   have    a   contribution   to   make. 

We   hooe   you   will   n^ive   us   your  ideas    on  what   you 
think   should  be    done    and  how   we    can   do  the    -fob   better 
in   the    future. 


Washington,    D.    C.      20201 


14 


THE  ROLE  OF  REHABILITATION  CODES 

-  i       •         r    -  i  -  n  -    ■  -i . .   ■     ■    i-     i.i 

Maya  Riviere* 

I  hope  to  relate  anything;  I  can  contribute  to  this 
meeting  to  more  than  just  impairment  of  visual  function, 
because  our  entire  work  with  The  Rehabilitation  Codes  for 
the  last  nine  years  has  been  to  develoo  a  thinking  structure, 
a  vocabulary,  a  set  of   descriotions ,  for  getting  to  know  the 
person  who  has  the  oroblem  of  imoairment.   This  is  our  bias, 
rather  than  primarily  to  follow  the  traditional  way  of  identify- 
ing and  labeling  him  by  his  oathology.   "M.  D."  used  to  mean 
Ho-^tor  of  Medicine;  now  more  often  I  see  it  used  to  mean 
"muscular  dystroDhy." 

Our  historical  practice  has  been  to  examine  pathologies, 
not  people,  and  then  to  label  the  people  by  the  oathology. 
This  system  is  detrimental  to  the  implementation  of  the 
services  which  we  are  trying  to  give  to  oeoole. 

If  we  call  a  person  "blind",  we  immediately  project  a 
stereotype  of  an  inactive  person  who  is  sitting  useless  or 
shuffling  along  with  a  white  cane  unable  to  do  anything 
productive,  or  else  working  in  a  limited  number  of  trades, 
possibly  in  the  offices  of  some  so-called  charitable 
institution.   This  is  a  stigmatizing  conception  expressed 
by  verbalizing  out-of-date  labels.   The  fact  that  the 
famous  Snellen  monograph  with  its  numerical  measurements 
was  presented  to  the  world  in  1862  does  not  invalidate  the 
measurements.   But  we  must  question  the  use  to  which  they 
have  been  put,  especially  in  legislation.   Having  worked 
with  our  committee  now  since  I960,  trying  to  convert  the 
established  measurements  of  vision  into  an  impairment 
code  so  as  to  describe  current  and  available  function, 
I  have  come  to  wonder  whether  it  is  not  time  to  take  a 
bold  leap  out  of  the  19th  century. 

The  concent  of  our  work  is  to  provide  language  to  use 
in  interpreting  the  facts  of  a  case  to  the  people  who  are 
most  immediately  concerned  with  it — the  person  who  has  the 
oroblem,  his  family,  and  his  immediate  contacts.   If  you 
Dresent  that  person  to  himself  by  a  pathology  label,  you  damage 
him  in  his  own  eyes,  and  if  you  oresent  it  to  his  family, 
friends,  and  potential  employers,  school  teachers,  or  what- 
ever contacts  he  has  in  the  community,  by  saying  that  he  is , 
for  instance,  a  cerebral  palsy  you  are  damaging  him  in  their 
eyes.   Nobody  even  bothers  to  say  that  he  is  "cerebral 
palsied";  he  is  a  "cerebral  Daisy";  or  he  is  a  cataract. 


*D. Phil. (Oxon. )  ,  Executive  Director,  Rehabilitation  Codes, 
Incorporated 

15 


May   I   ask,   when   is    a   "cataract"?      I    ask  this    because    I   haven't 
been    able,    in   six   years   of  work,   to    get   any    definitive    state- 
ment   as   to   when   a  oerson   whose    vision    is   beginning  to   fail 
because    of   a   develooiog   cataract    actuallv   is    labeled   "a   cataract"? 
Unless   we    can    answer  this    kind   of  question,    rehabilitation, 
which   is    an   organized,   multi-orofessional  effort,    will    fail 
to   meet   the    demands    of   the    situation    faced  by  each   oatient. 

How   can  we    get   these   oeoole   to  work   together  and  under- 
stand each   other  when    they    are    all    talking   foreign    languages 
which   they   have   been   taught    in  their  seoarate    disciolines? 
Each   orofession   has    its   own  orofessional   area   of  interest 
and   its    own  orofessional   terminology.      In   rehabilitation, 
we    meet    a   rehabilitant   only  when  his   oroblems   are    such   that 
he    can't  handle   them  by   himself,      I   had  the    fortunate   ex- 
oerience   some   years   ago   of   going   through   an  entire    series 
of  oatient    follow-uo   studies,    categorized  by  oathology 
labels.      However,    I   wanted  to  know  what  haooened  to   the 
oerson   who   had  the   oroblem,    regardless    of  the    diagnosis. 
If  you   look    at    most    case    records,   you   can't    find   out.      If 
you    look    at    oatients'    records,   at   the   urinalysis    reoorts, 
the   temoerature    charts,   etc.,    you    find   all   the    clinical 
details    there,    yet   you   can    get   no    idea  what   was    going   on 
with   the   oerson  who  was    in   bed.      You   can't    find   out   what 
haooened  to  him  as   the    result   of  the    clinical   treatment 
or  after  he   went  home,   because   no   one  knows   how  to 
describe   him  as    a  oerson   or  the   effects    of  service    on 
his   oroblems.      It   is   no  wonder   that    some   oeoole   have  beerun 
to  question   what    case    records    are    suooosed  to  be    good   for. 

In    1957   such   a  questioning  grouD   in   Mew  York   City    came 
to   a   foundation,    The    Association    for  the    Aid  of  Criooled 
Children,   which  was    financing   their   demonstration   in  the 
Borough   of  Queens.      This   was    a  diagnostic    and  evaluation 
clinic  where   a   comolete   examination   resulted  in   a    good 
diagnostic   work-uo    for  handicaooed   children.      The   reports 
were   then   sent   to    family  ohysicians    to  work   out   with  the 
oarfents   some    sort   of   schedule   by  which   the    individual   child 
was   to  be   served    for  some   vears   to   come.      But    when   the    family 
ohysicians    began    getting  these   excellent    reoorts,    they   came 
back   to  the    clinic   saying,    "we    simoly   cannot    interoret   the 
clinical   details    in   terms   of  the   imolications    for  a   given 
child  because   every    child  is    different,   everv    family   is 
different.      Some    of  the   oarents   are   highly   intelligent   and 
coooerative,    others   are   hostile    or  oerhaos    illiterate.      The 
circumstances   vary  every    time   we   meet   a  new   human   being". 

Well,    if  you   are    going  to   measure   oeoole    and   label  them 
all   "legally   blind",    and  not   take    into   account  the    age    of 
onset,    the   education,   the    intelligence,   motivations,    and 
maturity   of  the   oerson,   his    assets    and  the    resources,   the 
helo    given   by  his    family   and  others    in  his    suooor-tive 
community,   you   are    simoly    relegating  him  to   a   mass   statistic. 

16 


This    offers    little    to    go   on    living   for.      Peoole    don't    go   on 
living  in    terms    of   functions   they   have    lost;    they    go   on 
living   in   terms   of  what    they   can    do. 

But    if  you   look   in   most   case    records,    you   see   no   over-all 
evaluation    of  the   oatient    as    a  person,    living   in  his 
accustomed  and   aoorooriate   environment    at   home.      What    if  he 
is    a   school   child   going   to   school,    or  what    if  she   is    a 
housewife    doing  household   tasks?      All   you   see    is    a 
clinical   description   of   a  pathological  process    or 
condition. 

One    result    of  the   inability    of   family   ohysicians   in 
Queens   to   interpret   the    imolications   of   the    clinical   labels 
to  the    family   and  make   olans    for  a   child's   services   was   a 
one-year  project,   which   over  the   oast  nine   years   has    come 
to   be   known    as  The    Rehabilitation   Codes.      Now,    if  you  will 
accept    the    term  "code"   not    as   being  a  numerical   or   statis- 
tical  arrangement,    but    rather  a   code    of  behavior  and  an 
aooroach   to   the   oerson   who   has   oroblems,    you   will    find 
that    The    Rehabilitation   Codes    are    a   working   record   struc- 
ture   for   the    multi-orofessional  peoole    who  may   be    drawn 
into  exchanging   information    because    of  the    individual's 
unique    and   multi-faceted  needs.      The    one   year  oro.iect   started 
as   a   survey    of  how  orofessional  oeople    across   the    country 
were    identifying  the   kinds    of  problems   that   arose    out    of 
musculo-skeletal   and  neuro-muscular  conditions    alone.      Now, 
you  see    right    there,    the    focus   was    on    the   oathological 
condition,   not   the    oerson   having   it.      Nine   years   ago   there 
was    still   a   tremendous   emohasis    on   the   oroblems    of   mobility, 
more    talk   about    amputees,    or  a   joint    of   the    little    finger, 
as    ooposed   to   the   human    function   of   aooroximat ion — thumb    to 
fingers    of  the   hand   as   an   extension   of   the   brain — of   "seeing" 
and   "hearing"    as   human    functions    of    learning  and   communication. 

In   criss-crossing   the    country,    visiting   over   900   orograms, 
I   became    aware    that   the    case    records   orovided    little    infor- 
mation   of  use   to  the   several   orofessions    that   might   be    working 
with   the    same   oatient.      In   a   child's    record,    there   was    rarely 
any   mention    of  the    parents.      In   an    adult's    record,    you   didn't 
know   if  he    lived   alone,    in   a   rooming   house,    or  had  been    in   a 
half  dozen    institutions    during  the   past   half  dozen   years. 
There   was  no   supoortive    information   to  use   as    a  basis    for 
making  decisions   to   give    soecific    service.      Also,    there    was 
no   indication   of   attempts   to  measure    the   quality    or  effect- 
iveness   of  the   service. 

We   were    already    in    contact   with  the    Surgeon   General   of 
the    U.    S.    Public   Health   Service,    who   had   set   up    The    National 
Committee    on   Vital   and   Health  Statistics   at   the    request    of  the 

17 


World   Health    Organization    in    19^9    with    a   number   of   sub- 
committees.      The    Chairman    of   the    Subcommittee    on   the 
Physical   Imoariment    Code    was    one    of   the    initiators    of 
The    Rehabilitation   Codes    oroiect.      Work    on   the    imoairment 
code    had   started    in    1951,    and    it    was    to   be    designed    for 
coding   data    from   the    agency    giving   the    services    Known    as 
rehabilitation.       In    1959,    the    further   development    of   that 
imoairment    code    was    turned   over   to    The    Rehabilitation 
Codes    oro.ject,    after   I    had    been    asked    to   serve    on    the 
Surgeon    General's    subcommittee.       Its   Chairman    continued 
to    serve    on    the    project's    govern  in r  committee.       It    was 
as   oart    of   that    develooment    that    we    received    grants 
(1961-63)    from  the   National   Institute    of  Neurological   Diseases 
and   Blindness    to    concentrate    work    on    an    imoairment    code    section 
for   communicative    disorders.       Under   this    heading  we    include 
imoairment    of   voice    function,    imoairment    of  hearing    function, 
imoairment    of   soeech    function    (which    we    limited    to   articulation 
oroblems    only),    and    imoairment    of    language    function.       Please 
note   that   we   added   the   word   "^unction"   to  each    because    we 
were   not    talking  about   orrrans    alone. 

"•/hen    we    be^an    work    in    I960    on    impairment    of   visual    ^unction 
we    were    not    concerned   with    the   eye    as    an    organ,    but    with    the 
binocular   "seeinn-"    function.      This,    of   course,    reminds    ne    that 
your  oresident    mentioned    the    fact    that    you   do  not    examine    eyes 
with   droos    in    them   because    this    immediately    creates    an    abnormal 
state.      You   are    concerned  with   evaluating   a   two-eyed    function. 

But    how    does    a   oerson    see?      Mow    does    he    use    the    function 
he    has,    sometimes    in  ways    which   his    "measurements"    seem  to 
indicate    that    he    cannot?      Why    do   two    oeoole    with    the    same 
measurements    manage    in   comoletely    different    ways,    or   fail 
to   manaere,    the    same    activities?      We    do  not   know,   because    as 
orofessionals    we    have    confined    most    of   our   study    to   his 
oatholoc;y.      Yet,    we    the   professionals   are,    for   the   oatient, 
part    of   the    abnormality.      Being    tak^n    out    of  his    family    into 
an    institution    or  hosoitai    is    an    abnormality.      What    is 
"normal"    for  him   or   aoorooriate    for  him   is    to   be    healthv, 
at    home,    working,    doinn;   all   the    things    in   his    neighborhood 
that    he    considers    "livinr".      This    ooint    of    view    requires 
re-orientation.       We    must    learn    to    look    at    the    "oatient"    as 
a  human   beinn;   first.      We    must    treat   his   oathology   if  oossible, 
but    the    fundamental    task    is    to   he  In   him    go    on    living   in   his 
own   terms. 

The    Rehabilitation    Codes    Pro";ram   on    Imoairment    of   Visual 
Function   in   I960    invited   a    errouo    of   pen  resent  at  ives    from  the 
major  orofessional ,    rehabilitation,    federal,    and   other  service 
agencies,    to   work    torether,      Tne    initial   nuroose    was    to   secure 
agreement    uoon   the    most   useful    of  the    many   established   svstems 


.13 


of   measurements   and   uoon   standard    testing   conditions.      Granted 
that    with   different    illumination,    contrast,    color,    and    fatigue 
(the   examiner's    as   well    as   the   oatient's),    visual    function   can 
be    found    to   vary    from  one   examination   to   the   next,    and   its 
measurements   can   vary    from  one   oeriod  to   the   next.      This    only 
requires    that    we   create    a    serial    record   form  on    which   the 
measurements   at    any   date    or  time    can    be    set    down    in  consis- 
tent  terms   to   orovide    a   comoarison   and  establish   the    trend 
in    the    changes.      We   are   now   in   1966    at    the   ooint    of  agreement 
on    the    measurements,    but    must   take    the    next    steo    to    specify 
which   measurements   mean   absence  ,    me  a  sure  able    limitation  ,    and 
those    (to    date)    un  me  a  sure  able    dysfunctions    for   a    consistent 
section    on    imoairment    of   visual    function    to    be    included    in 
the    3u--geon    General's    Impairment    Code. 

We    are    currently   involved   in    field  tests   of   the    measure- 
ments   to   see   how  they   relate    to   what    a  oerson    so  measured   can 
or   cannot    do.      We   exoect    to  examine    some   50    oeople   who  are 
legally    blind,    newly   blinded,    unimpaired   so   far   as   we   know, 
or   known   to   have    various    visual    imoairments.      A    detailed   case 
history    on   each    will    record   what    he    can    do,    what    he    cannot    do, 
and   what    kind   of   activity   he   has   Droblems   with.       In   June    (1966) 
we   are    holding   a  working  conference    to   which   a   grouD   of   ex- 
perienced  oeople    will   be   invited.      We    shall    renort    on   the 
field   test    results   and  ask   them  to  help   us    formulate    the 
implied   impairment,    from  the    ooint    of   view   of   the   human 
being's    human    function    of   "seeing". 


The    draft    of   the    impairment    code   must   then   be    field- 
tested   to   see   how   useful   the    single   code   entry   descriptions 
are    in    following  the    function    of  a  person    over  a  oeriod   of 
time.      The    instructions    for  using  the   Measurements    Code,    the 
instrumentation,    and   the    testing  conditions   and   procedures 
must   also  be    further   developed   or  adapted   so   that    across    the 
whole   country    consistent    methods    can   in   the    future   bep;in    to 
oroduce   consistent    information    leading   to    improved   services. 
The    information    will   be    more    easily   exchanged   when    it    is 
couched    in   commonly    used   and    commonly    understood  terms.      The 
resultant   accumulated   data  which   will   be    directly   encoded 
for  comouter   analysis    may   lead   to   useful   research    for  ore- 
vention    of    imoairment,    as    well    as    more    effective    service 
for  those    already   imoaired. 

We    may   even    find   out    how   oeople    "see"    what    they    do    see. 
We    may    learn   how   to    teach   peoole    better   use    of   the    visual 
function   they   have. 

i860  Broadway 

New   York,    New   York      1002  3 


19 


INDUSTRY  VI5WS  VISUAL  IMPAIRMENT 


Rlch'-ird  Weinberg* 


This    March    was    the    2  3rd    anniversary    of   the    eye    care 
program   at    Soerry    Gyroscope    Company,    located   in   Treat    Neck, 
Long   Island.       I    was    instrumental    in  establishinf   this 
program  and   was   Supervisor   of  the    Eye    Service    in   its  early 
years    during   World    War   IT.       It    still    continues    to    serve 
Soerry  employees.       It    is    a   shock   to   realize    that   2  3   years 
have    gone    by    so    rapidly. 

When   the    Soerry  program  was   initiated,    it    included   the 
talents    of   ophthalmologists ,    ootometrists ,   psychologists , 
medical   personnel,   nurses,    safety   engineers,    and    lay 
technicians.      It    cared    ror  many  thousands    of  oeoDle.      It 
still    does  —  screening  them   for  employment,   providing  them 
with    safety   eye   wear,    and  providing  them  with    special  eye 
wear  where   needed.      It    is    concerned  with  environmental 
conditions   and   with   .1  ob    design.      Dr.    Herman   Sager  has   been 
the    chief   of   that    program  since    I    left    there    over  20   years 
ago. 

In   the   war  years    we   employed   a  number   of  employees 
with   very   poor  vision.      Prooerly  placed,    they   performed  their 
tasks    very   satisfactorily.      It    is    my    understanding  that   the 
company   does   not   now  employ  persons   with   20/200    acuity,    or 
less,    and   that    the   totally  blind  have   not   been   employed  by 
the    comoany   in   many   years.      This    is    unfortunate.      To  my 
knowledge    there    are    few   industries   that   employ  persons 
handicapped  with    limited   vision. 

It   must   be    remembered  that   it    is   not    the    large    companies 
that   employ   the    majority   of  the.  working  population    in   this 
country.      Ninety-nine   percent   of   all  plants,   employing  88 
percent    of  the    labor   force,    can   be    classified  as   small 
establishments   hiring  under  500   employees.      Here    is   where 
there    is   the    greatest   need    for  modern    simplified  methods 
of  vision    screening  and   the    techniques    of  coping  with  the 
problems    of  visual   safety   and   visual  efficiency    requirements. 
Mark   Twain    once    used   the    term   "petrified    truth".       If,    in 
these   23   years,    I   have   acquired  any   "petrified   truths",    one 
would  be   that   if   an  employee   needs    glasses,   someone    is    already 
paying   for  them — the   employer  by   decreased  production,    the 
consumer  by   inferior  product,    or  society   at    large   by  medical 


*Ph.  D.  ,    Chief,    Visual    and    Auditory    Laboratory,    Georgetown 
Clinical   Research   Laboratory,    Federal   Aviation    Agency. 


20 


and   social   costs    out   of   its    own   oay  envelooe.      All  this    is 
without   anyone's   knowledge,    of   course.      It   would  be    more 
economical   to   get   those    glasses    on   him. 

Another   situation    becomes    more    significant    to    our 
society    as   the   years    roll   by.      We   have    about    18    million 
men    and   women    in    the    United   States    aged   65    and    older,    and 
this    grouo    is    increasing   at    the    rate    of    over   400, 000   oer 
year.      Concern   with    the    visually   handicaooed   within   this 
grouo    becomes   ever   greater.      Geriatrics   takes    on   new 
meaning    for  those    in    the    ^ield    of   visual    care.       Investi- 
gations   of   methods    to   keeD    older   age    emoloyees    ooeratinp- 
at    oeak   efficiency    frequently    result    in  the    recommendations 
for   more    and  better  eye    care.      The    contributions   of  the    oohthalmic 
industry    and  the    oohthalmic   orofessions   have   never  been   more 
imoortant . 

Those   of  you   who    are    orofessionally    concerned  with   the 
detection,    care,    and   rehabilitation    of  those    afflicted  with 
subnormal   vision,    are   ever  more    frequently   confronted  with   the 
problems   of   the   blinding   diseases.      Diabetic    retinooathy,    for 
example,   now   accounts    for   16  percent   of  all  blindness.      Glaucoma 
brings    about    3500  new   cases    of  blindness   in   our   country's   oooulation 
every  year;    and  there    are   now,    according  to  some   estimates,    30,000 
oeoole    in  the    United  States    completely   blind,    and   another   150,000 
blind   in   one   eye, as    a   result    of   glaucoma. 

These   oroblems   will   never  be    resolved  by    any    one^  grouo    of 
specialists.      They    are   oroblems   that    can   be    confronted   only   bv 
interprofessional    action.      I    should    like    to   believe    that   the 
orofessions    are   now  working  together   on    an    inte  rdisciolinary 
level.       A   meeting  such    as    this    aupcurs    well    for   the    future. 

Someone  might  conjecture  that  oeoole  with  subnormal  vision 
do  not  drive  automobiles.  Unfortunately,  they  do.  The  activities 
of  the  visually  handicaooed  are  carried  over  into  everyday  living, 
including  automobile  driving.  In  most  states  auto  licenses  can  be 
renewed  without  vision  retesting.  Some  oeoole  who  can  barely  see, 
drive    cars.      We    need  tighter   laws   in  this    respect. 

Those   who   would   be    concerned  with  the    visually-limited  need 
acquisition   of  knowledge    in   develoomental   and  oediatric   vision, 
eye   orotection,    the   use    of  orosthetics   in   subnormal   vision,    the 
training   of  those    so   limited,    and  even   the    care    of  the   blind. 
Emohasis   has   to  be    on   team  endeavor.      Those   who    can   make    a 
meaningful    contribution    to  the    assistance    of   the   visually- 
limited   must    be   encouraged   to  oarticioate--a  kind    of  voluntary 
conscription. 

The   medical   director  of  a   major  industrial   corporation 
wrote   me    that   there    still   are   hurdles    res:ardin°;   insurance    when 
hiring  emoloyees   with   limited   vision.      The    insurance   oroblem 


21 


needs    further  review.      He    indicated   that   many  oeoole   who  have 
limited  vision   are   emoloyable    and   in  no   way    handicaooed   when 
olaced  orooerly   in    industrial   work.      He,    for  examole,    makes 
certain   that   no  oerson   with  high  myonia  does    any  heavy   lifting. 
This    is    a  orecaution    against    retinal   detachment.      His    final 
comment    was    that    it   was   uo   to    "comoany  oolicy"    and  the    re- 
commendations  of  the    medical   director  as   to  whether  visually- 
limited  peoole    would  be   hired.      Obviously,   this    oresents    another 
educational   task. 

The   truly   enlightened  employer  will   see    to   it   that   his 
employees    have   periodic   vision   rechecks.      This    should   include 
oohthalmoscopy ,    visual   fields   and   tonometric   measurements. 
It    should  include    careful  evaluation   of   the   emoloyee's    vision 
and  the    tasks   uDon  which   he    is    called  to   oerform.      It    should 
include   keeoing   careful   records. 

No   one   has   yet    satisfactorily   met   the   oroblem  of  how 
to   bring  such   services    to  the    small    conroanies    and  places   of 
emoloyment.      Emoloyers    in    these   establishments    regard   such 
a  orogram  as   too  expensive    and   too    comorehensive    for   their 
needs.      Most    frequently,    I   am   afraid,    thev   never  even   think 
about   it.      Perhaos   this   Droblem   can   best   be   handled  through 
community   soonsored  eye    care   oroerams.      This    is    an   extensive 
problem  that   needs   elaboration.      Larger  industries   have 
suoolied  us    with    such    data   as   these:      50   oercent    of  those 
employed   lack    ootimum  vision    for  what   they    are    doing.      Over 
60   percent    of  all   workers   who   are    rated  below  average    in 
efficiency  have    less    than   ootimum  vision.      Twenty  oercent   of 
the   employed  make    80   percent    of   the    first-aid   visits.      The 
enlightened  industries   today    recognize    these    facts    and   are 
doing  what    they    can,    beginning  in  the   ore-employment   testing, 
the   emoloyment    medical   examination,    and   finally   in  the   oeriodic 
re-examination.      Some    day,    the   smaller  establishments   will    find 
the   means   to   have    these    constructive   measures    ooerative    for 
their  Dersonnel. 

In    closing,    I   should   like    to   give   soecial   mention    to   such 
oersons    as    Mr.    Jack   O'Neill    of   the    National   Society    for  the 
Prevention    of  Blindness    for  his    lifelong  work   in  the   oromotion 
of  eye    safety,    and   to    the    committees   of   the    American   Ootometric 
Association   and   the    American   Medical    Association   which    supoorted 
and   initiated   vision   safety   measures   in   industry. 


Washington   25,    D.    C. 


22 


WORKSHOP    DISCUSSION   SESSION 
Panel    1 


MRS.    ADA    BARMETT   STOUGH*:       I    come    from  the    Administration 
on   Aging,    and   we   are    interested   in   one    segment    of   the   popula- 
tion  included  by   one    SDeaker  of   this    morning  under  the    label 
"the    forgotten   peoole".      Dr.    Feinberg  mentioned  the   oroblem 
of  encouraging  older  people    to   seek   the    sight   necessary   for 
employment.      A    far   greater  problem  lies   in    the    large    segment 
of   older  people    who  have    retired.      We   believe    that    one    of  the 
most   ooignant   needs    of  that   older   segment    of   the    population 
is    the    ability  to   keep    a   zest    for   living.      They  have    retired 
after  years   of  making  a   living  without  having  built   inner 
resources   that   are   necessary    to   keep   on   wanting  to   live;    and 
if  you  add   that   handicap   to  that    visual   impairment,   you   get 
a  mental   and  a  physical   situation   that   makes    for   greater  and 
greater  loneliness   and  more    social   isolation. 

One    of  the    objectives   in   the    whole    field   of  aging  is 
to   make    services   available    to   these   people   not   only  housing 
services,    health   services,    income    services,    recreation 
services,    and   so   on,    but    also  the    great    service    done   by   the 
people    in   your  profession   to   reach   these   people,    and  after 
reaching  them,    to  Drovide    the   kind   of  devices   or   glasses    or 
whatever  it    takes   to   help   these   people   to   visual   function 
and   to   less    and   less   impaired   respect;    in  other  words,    to 
feel   competent    in  matters    of   vision.      In   the   new  programs 
for  the    aging,    that    are    going  to   be    (we  hope)    increased 
throughout    the    United   States,    we  hope   to  have    more    and 
more    information   at   senior   centers    so   older  peoole   can  be 
directed  to   the   kinds   of  services    or  to  the   people   who  will 
be    able   to   give    those    services.      This   is   why   we   certainly 
would  Plea   for  the   co-operation    of   ootometric  associations 
throughout   the   nation. 

I   think  the   big  challenge   here    is    to  help   these   people 
to   ooerate   and  to   function   within    society   as    it    is   today. 
In   other  words,    they   should  be   able   to   read   standard  print 
and  to   operate    as   normally   as   they   can.      For   those    instances 
where   this    is   not   possible,    we   would    like   to  encourage   the 
large   orint   books   which   you  have    assisted   in   developing,    and 
we    would   like   to  encourage    large   print    hymn   books   and  wider 
use    of   those    visual   devices   that   will  help  people   who  are 
not    rehabilitated  to   function   better. 


*Assistant   to   the    Commissioner  on   Aging,    Administration  on   Aging, 
U.S.    Department    of  Health,   Education   and  Welfare,    Washington,    D.C. 


23 


It    is   unfortunate   that   the   new   techniques    to   improve 
and  increase   the    vision   of  the   elderly   are    so   little   known 
and  used  by   the   public.      I   would   suggest   that   there    are 
several   reasons: 

(1)  The   interests    of  the    optometrists   themselves 
have   not   been    sufficiently   aroused   in  serving  the 
elderly.      They   have   not  yet    caught    a   glimpse 

of   the   excitement   which    comes   when  newer  devices 
bring  to   old  Deople    a  renewed  zest   for  living. 

(2)  Community   committees    and  councils   on    aging 
have   not    sought   the    support   of   optometrists 
and  have   not   included  them  in   community 
planning.      Too   few  people   know  what  you 
optometrists   have   to   offer  and  have   not 
sought   out   your  services. 

I  would  make    a  plea   for  active    committees   on   aid  to 
the   visually  handicapped  in  your   local   chapters.      I  would 
be   sure    that   they   Include    a  strong  emphasis   on   older  people. 
I   would  hope   that   you   could  do    some    real   promotion   on  the 
services   your  profession    can   render. 


QUESTION   TO    MRS.    STOUGH:      What    about   the    great    costs 
of   care    for  aging  persons,    falling  on  their  families?      How 
can  these    families   or  these   people   be    assisted,    financially? 

MRS.    STOUGH:      Well,   this    is    a   $61,000   question.      We 
know  that   under  the    medical   assistance   program   for  the 
indigent   or  the   medically   indigent,    some    states   have 
recently  made    a  Social  Security   Amendment   to  make    avail- 
able  more    financial   assistance    through  the   state.      Some 
states   do   include    correction   of  vision   as    a  part   of  this 
medical  payment,   but   this   is   not  true   in  all   of  the    states. 
That    is    the  number  one   aspect    of  it.      The   second  is,    I 
understand,   that   some    labor  unions    and  some   of  the    organizations 
for  senior   citizens    are    going  to   try    for  an   amendment   to  the 
Medicare   Bill   which  will   allow  expenses    for  devices   such  as 
glasses,   hearing   aids   and  so    forth,    to   be   covered  under  the 
voluntary   medical   insurance   plan. 


24 


QUESTION!    DIRECTED  TO    MR.    WALLACE    WATKINS*:      What    services 
are    available    to   help   sheltered  workshoo   employees   move    into 
employment   by   regular  industry? 


MR.    WATKINS:      Basically,    sheltered  workshoDS    of  all 
varieties  ,    governmental    or  private,    attempt  to  provide 
vocational    rehabilitation   services,   which,    initially, 
attermot   to    determine   what    functions    or  skills    does   the 
man  presently  have.      This    is    done    largely   through  testing, 
either  on-the-job   testing  or  psychological   testing,    or   so 
on;   but   this    is    merely   a    functional  evaluation.      Then   the 
rehabilitant   must    go  through    several   steps    or  different 
programs   or  whatever  you   call    it,    aimed   at    develooing 
work    readiness. 

We    must   recognize    that    we   have   many  people — partially 
sighted  people,    as   well   as   those   with   other  disabilities  — 
who   simply   do  not   know  the    rudiments    of  what   work   is. 
Does    an  employer  expect    you   to   work  eight  hours    for 
eight   hours   pay,    or  do  you   get    to   go    for   "coffee"   every 
time   you    feel   a  little   thirst?      The    develooment    of  work 
skills    and  work   habits   is    really   one    of  the   most    imoortant 
services   provided  by  Workshop,    and   it    is    in  this    area   that 
we    get    into   many   of  the    special   services--abnormal  vision 
services    and   medical   services — while    we    remain  concerned 
with  treating,   as    Dr.    McCrary   says,    the   whole   man. 


Now  this    is   where   we    get    into   all   sorts    of  services 
to   preDare    the    man    for  work.      Our  workshoos    can   do   some 
soecific  job   training,    although   we    don't   do   a   great    deal 
of  it.      I   think  that  phase   has   been    overplayed  a  bit,   but 
there    are    certain  work   skills  which   are    taught   in  the 
workshop. 

Services   of  several   different   varieties   should  also   be 
mentioned.      One   of  them  is    simply    long  term  emoloyment — some 
people   never  move    out   of   a  workshop — and  this    is    a   valid 
service    for  them.      Another  main   area   of   service    is    trans- 
itional emoloyment,   which   is    basically   a   short   period   of 
employment — many  work    from   3  to  6    months,   a  year,    or  maybe 
longer — with   the    objective   being  always   to  move   them  out. 
Then   we   have   placement    services  —  attempting  to  place   people 
in   regular,    competitive,   industry    or  business.      Placement 
is    a  major   function.      In   the    implementation   of  these    servi^. 
incidentally,    workshops   of  this   nature    traditionally    use    all 
of  the    services    of  the   Vocational   Rehabilitation   Administrati 
in  all   of  the   50   states.      It's   a  joint   venture. 


ces , 
on 


^Director   of   Field   Services,    Goodwill   Industries   of   America, 
1913   N   Street,    N.W.  ,    Washington,    D.    C.        20036 


25 


QUESTIONS   DIRECTED   TO   DR.    MACFARLAND:      3.      What    services 
are   being  rendered   in   rural   areas? 

A.      Services   are    provided  uniformly   throughout   the    State. 
In   rural   areas  where   professional   personnel   are   not   available, 
clients   are    transported   at    the   expense    of   the   agency  to   urban 
areas   where   they   can   have    the   benefit    of  soecialists'    examin- 
ations  and    follow-uo   treatment   or   surgery. 

Q.      Is   there   a    summary   of  the    "new  VRA   law"    available 
to   determine    services   available   and  how  to   obtain  them? 

A.      A    summary    of   the    "new  VRA   law"    is   available   and   may 
be   obtained  by  writing  to   Mr.    Russell   J.N.    Dean,    Assistant 
Commissioner,    Legislation  and  Public   Affairs,   Vocational 
Rehabilitation  Administration,    Washington,    D.    C.      20201. 

Q.      Often   V.R.    Chiefs   are   not   properly   informed   of 
optometry's   training  and  knowledge    in  the    field   of   low 
vision   care.      Will  Vocational   Rehabilitation   Administration 
plans   include    regional   conferences   to  better  educate   and 
up-date    the    thinking  of  State   Rehabilitation   personnel? 

A.      As   I    Indicated   in   my   formal   remarks,    State    agency 
directors   serving  the   blind  and  visually  handicapped  are 
quite   knowledgeable   with   resoect   to   ophthalmological   and 
optometric    services,   e.g.,    optometrists   are    involved   in 
our    low  vision   aids   clinics   and  work   closely  with   the 
agencies   that   have    prevention   of   blindness    departments. 
Also,    we   are   expecting  to  convene    a  national   seminar  on 
the    operation   of   low  vision   clinics   which   should  add 
emphasis   on   this   point    of   optometric    knowledge   and  concern. 

Q.      What    is  the   current   status   of  the   Demonstration   Grant 
Project    for  Optical   Aids   Clinics? 

A.      At    present   we  have   23   optical   aids   clinics.      Prior 
to   the    1965   Vocational   Rehabilitation   Act   Amendments,    these 
were    sponsored  by   our   Research   and   Demonstration   Grants 
Division.      Under  the   new  provisions,    the   program  will  be 
expanded  to   include   at    least    40   clinics    but    will   be    supported 
through   innovation   or  expansion   grants   under  the    auspices    of 
the    State   Vocational   Rehabilitation   Agencies. 

Q.      How  can   we   cross   state    lines    in   getting  services 
when   it    is   faster  and   cheaper  to   obtain   them  in  a  neighboring 
state   than   to   go   greater  distances   within   a   state? 


26 


A.      In   VRA  oro^rams  there    is  nothing  which   restricts 
a   state    agency    from  sending   a  client    across    state    lines   to 
obtain    services   which  either   aren't   available    in  the    original 
state    or  services   which   can   be   orovided  more   economically    for 
any   of  a  number   of*   reasons. 

QUESTION    DIRECTED   TO   DR.    RIVIERE:      In    your   Rehabilitation 
Codes    oroiect,   who  will   measure    "environmental    ^actors"    and 
equate   measurements   by   O.D.s    or  M.D.s   with   the   measurements 
by  osychologists    and   by   social   workers    on    these    same    factors? 

DR.    RIVIERE:      Before    we    can   be^in   to   deal   with   this 
question,   we    must    concern    ourselves   with   two  orior  questions 
which    are    as   yet    unanswered.      How   are   we    going  to   get    measure- 
ments   of  "environmental    distractions"?      We   are    convinced  this 
is    a  oroblem   of   central   imoor-tance ,    yet    it    is   also  one    that 
varies   widely    from  oerson   to  oerson    and   is    only   slightly   re- 
lated to  his    soecific    "disability'.'      Also,    we   have   the    disturbing; 
question   that   our  oresent   tests    largely    fail  to   answer:      "How 
is   this    man    goin°;  to  oerform  when  he    leaves    our  office    and   goes 
into   the    street,    or  to  his   job?"      Before   we    can   worry    about   any 
Droblems    of  "equating",    we    must    first   have    at    least    one    test 
that   seems   to  have    some    validity.      In   most    cases   we    lack   even 
one    such  test    right  now. 


QUESTION    DIRECTED    TO    DR.    WEINBERG:      How    can    employers 
be   educated  to  the    ^act    that   visually-limited  individuals 
can   qualify    for  wider  emoloyment    than    they   now  enloy? 

DR.    PEINBERg;      This    is    a  very    complex  oroblem.      I   think 
a  ooint  that's    crucial  here    involves    the    insurance    comoanies. 
Insurance    comoanies   which    carry   the   workmen' s    comoensation 
risks    seemingly    cannot  be   educated   to  the    fact    that   oeoole 
who   are   handicaooed   can   be   safely   emoloved.      This   also  me^ns 
that   there   hss    to   be    some    governmental   regulation    in   terms 
of  second   in.lury   clauses.      It   also  means    that    American   manage- 
ment   associations   have    to  be    indoctrinated  with  the   notion 
that    they    can   hire   handicaooed  oeoole.      It    also   means   that 
the    American   Medical   Association    and   the   Industrial   Dhysicians 
Grouo,   which   run   the   medical   deoartment,   have    to  be    further 
educated.      It    also   means    that    the    American    Association    of 
Safety   Engineers   has   to   be    sufficiently   convinced  that    this 
is    a  worthwhile   orolect.      In    short,    I   think   there    is    a  olace 
of  leadershio   here    por   some    governmental    industry   significantly 
imoortant   to   influence    the    various   other  agencies    involved. 


27 


UNIDENTIFIED    COMMENT   FROM   THE    ^LOOR :      I    must    defend   the 
emnlover    lust    a  bit.      All   or  these    things   which   Dr.    ^einbere: 
has    said   are    all    geqred   to    o-et    the    emnlover   to   hire    a   man. 
There    are,    however,    one    or  two   other  things    involved   here: 
one    is    that    for   manv    industries    the    union    controls    which 
kind  of   iobs   are    used  as   entrance    iobs.      ffor   instance, 
certain    assemblv    1obs    in   manv    factories    are    reserved    ^or 
women.       These    often   haooen    to    also   be    verv    pcood    for  blind 
and  oartially-sighted  neonle.      Yet,    as    ^ar   as   emnloyiner 
visually-limited  nersons    is   concerned,    these   .iobs   are 
simoly  eliminated;   not   by  management ,   but   by  union   contract. 
So  this    is   a    factor   I  think  you  must    recognize.      Unions    are 
a  oartner   in   this    emolovment. 

Secondly,    there   is    a  very  nractical  oroblem   in   that 
in   most   American   plants   today,    flexibility   is   crucial,    and 
most   emoloyees    must    work   on   three    different    -fobs    instead  of 
lust    one.      Thus,    flexibility   in   our  t^qinins:  ^nd  nrescrintions 
is   essential.      You   must   nrovide    for  oatient    flexibility  even 
if  it   requires    three   oairs   of*   classes    or   their  equivalent. 
Flexibility    is    simoly   a    fact    of   industrial    life   with   which 
both   you  and   the   emoloyer  must    live. 

UNIDENTIFIED   COMMENT    FROM  THE    FLOOR:      Many    of  you  have 
been   addressing  yourselves   to  oroblems   of   semantics    and 
wishful   thinking,    but   while    you   are    waiting   for  your* 
"functional   definitions"    and  the    achievement   of   "legislative 
goals",   what   are   we    going  to   do   rie;ht   todav? 

A   statement   I   would  make    is    that   there   are    a    e-reat 
many   services    available   today,    at    least    in   the    larger 
communities,   which   are   now  beinp;   imorooerly    or  inefficiently 
used  by   ootometrists ,    or  even   overlooked  entirely.      Each 
optometrist    should  consult,    in   his    own   community,    the 
community  welfare    council   or  an   agency    for  the   blind   or   a 
federal  agency.      I    suggest    the    local   community   welfare 
council  because    it    is  orobably   the   most   universally   available 
organization    in   any   given   town    of  anv   size.      I   would  make 
the   Doint   that    optometrists    in   the    local   ootometric    asso- 
ciations  and  the   auxiliaries   have   not  been   as   active    in   the 
total   community  olanning  of   services   and  needs    for  the 
oartially   sighted   as   they   could   and   should  have   been. 

I   also   point   to   figures    stated  by   Dr.    McCrary   this   morn- 
ing that   you  orovide    75   oercent    of  the   visual  needs    of   our 
nation.      I   think   an   aporoDriate    question    is:      Do  you  also 
orovide    75   percent    of  the    leadershio   which    is   necessary 


28 


to   see    that   all   people   are    receiving  the   necessary   services 
that    they   need?      Another  asoect   of  this   thing  has    to   do   with 
obtaining   services    in  smaller  communities.      Maybe   we   are 
doing  all   right    in   Houston,    Texas,    but   what    about   Chillicothe, 
Ohio  and  all   these    other   little   olaces?      ODtometry   has    to 
meet    the    full   needs   of  oeople   with   visual  problems,    regardless 
of  the    size    of   the    community    in  which   the    oatient    lives. 

These   are    questions   that    I   think   you  have    to   work   on, 
and   I    think   leadership   has   to  be   exercised  by  everybody, 
including  the   American   Optometric   Association,    in  trying 
to   resolve   some    of   these   problems. 

FURTHER   COMMENT    FROM   THE    FLOOR:       I   know   that    in   many 
local   communities   today   there    is   a   growing  need   to   develop 
a   register  of  all   the   various    services   and   institutions    in 
the    area   categorized  by   types    of   help    or  types   of  agencies. 

Here    is    one   area  needing   leadership    from  the   citizens 

of  the   community.      If  your  area  has   such  a   directory,    is    it 

up-to-date?      If  there  is   not   a   directory,    get   busy  and 
instigate    onel 

MODERATOR:      A   basic    answer   that    I   would  give    to   the   question 
of   our   supplying   75    percent    of  the    leadership   in   this   area   is 
this   conference    itself.      This   conference    is    one    of  the   basic 


steps   toward   a  more    adequate   assumption   of   optometry's    public 
responsibility   in   this    direction.      We're   not    going  to   be   able 
personally   to  provide   many   of   these   needed   services,    of  course 
we   all   recognize   that   many   of  the    services   of  which   we   are 
talking  are   services   that    will  be   provided  by   professionally- 
trained  people    in   the   areas   in   question.      But   we   do   feel   that 
we   need  to   know  much  more   about   these    services    so  that    we   may 
act   as   more   adequate    guides    and  as   a    source    of   advice   and   ■ 
counsel   as   we   bring  out    patients   toward   larger  economic   and 
social   integration. 

QUESTION    DIRECTED   TO   C.    EDWARD   WILLIAMS*:       How   can    we 
make    available   to   the    older  citizens   of   our  communities,    the 
advantages    of   our  present    successful   techniques   which   are 
designed  to   allow  them  to  work    in  their  normal  environments? 


*0.D.,    Member  Committee    on   Aid  to   the    Partially-Sighted, 
American   Optometric    Association,    612   Smoire    Building,    Denver, 
Colorado  80202 


29 


DR.    WILLIAMS:      We   were    talking  about    lines    of  visual 
aid  programs   and   about   the   intrinsic   value    they   have;    and 
it    occurred   to   me    that   not    all    o^   us    realize    that    our   most 
effective    nrocedures    involve    using  not    only    more    visual    aids; 
but    also    rehabilitation   techniques    designed   to   allow   agine: 
oersons    to    ooerate    without    change    in    the   environment    to  which 
they    have    been    so    lone-   accustomed.      We    want    them   still   to  be 
able    to   shoo,    to   sign    a   check,   to    fill   out    a    form,    to   dial   a 
phone,    or  read   their  mail  without   having   to   ask  their  neighbor 
to    do    so,    to    read   a   book    of  normal-sized  print  and   so    forth  — 
very  much    can   be    done    in   these    regions ;   thus,   you   give    an 
aging  oerson    a  helomate    that    they   may   have   been    lacking   for 
quite    a   while. 

When   a  oerson   has   to   ask  everyone   else    or  their  surround- 
ing  friends   to   do   these    things    for  them,   they    often   begin   to 
lose    their  idea   of  wanting  to   continue    living.      Ootometric 
services    can   orovide    a    loner  steo    of   return    from  this    No-Man's 
Land. 


COMMENT   BY   ERNEST   GAYNES*:      Our  electric   oower   comoany 
has    an   extremely    favorable    rate    which  they   would  orefer  not 
to  have    investigated;    and   as    a   result,    they   offer   a   great    deal 
of   service.      They    are    very   amenable    to  oublic   service    activity. 
They  will   modify   apoliances   wherever  oossible    for  the    visually 
handicaooed  upon   either  a   call    from   the    social  worker   or  uoon 
recommendation    from  somebody   involved   in   a   project .       As    a 
result,   we    can    always    offer  an    older  person   with   a  homemaker 
bent,    self-he lo,   because   her  electric    frying  nan    or  range  — 
all  these   things    can   be   either  coated,    masked   or  modified 
so   they    can  be    used. 

You'll    find  that   the    telenhone    comoany    can   also  be   en- 
listed in   helo.      por  instance,  there    is   the   new  ohone   which 
is   being  used — at    least,    in   our  area — which    involves   oush- 
button    dialing,    which   is   infinitely   much    simoler  to  use    than 
the   circular  dial.      Their  introduction    of  this    is    on   a  very 
regional   basis    at   the    moment,    yet   they   will    reolace    an 
instrument   uoon   request    for  a   visually   handicaooed  oerson. 
We   have    found  that    our  natural   gas    comoany,    which   offers 
home   heating  and   range   equipment    will   also  modify  their 
aooliances.      It's    a   case    of   finding   community    sources    often 
to  helo,    as    frequently  this   kind   of  modification,   which   is 
the    most    meaningful   as    far  as   the    individual   is    concerned, 
and  I    would   suggest   that   your   local  oublic   utilities   are 
an   excellent    source    of  helo   in   orocuring  some    of   these 
very    things. 


*0.D. ,    Low  Vision   Clinic,   Sinai   Hospital   of   Detroit,   6767  West 
Outer  Drive,    Detroit,    Michigan  482  35 

30 


WHAT   THE 
ADULT    HEALTH^   PROTECTION    ACT 
WILL   MEAN    TO   OPTOMETRY* 

Honorable   John   E.    Pogarty** 

Thank   you    for  your  invitation    to  oarticioate    in   the 
American    Optometric    Association's    Conference    on    Aid   to  the 
Visually    Limited.      While    I   would  have   been   haooy   to   attend 
this    luncheon    under   any    circumstances,    I    must    admit   that 
your   invitation    did    reach    me    at    the    orooer  osychological 
moment.       I    was    .just   outtinn:   some    finishing  touches    on    a 
bill    I    was    about    to    introduce    on    the    House    floor   to   be 
known   as    the    Adult    Health   Protection    Act    of   1966. 

The   bill    calls    for  the   establishment    of  adult  health 
orotection    centers    at    which   oersons    over  50   would  be    given 
free    a  battery    of   tests    designed  to   detect   abnormalities 
and   diseases    at   an   early   stage.      And,    included  among  the 
diseases    or   conditions    to  be    tested   under  this    orogram   is 
vision   inraairment. 

It    is    obvious   that  no   ae;e    group   in   our  Nation   has    a 
greater  need   for  vision    care    than  the   millions   who   have 
oassed  their  50th   year.      And   it    takes    little    analysis,   by 
and   large,    to    determine   that   a   major  oroportion    of  this 
grouo    is   not    adequately  orepared   financially   to   translate 
this    urgent  need   into   realization. 

While   no   one    can   oredict    accurately   the   aoorooriate 
interval   at    which    our  older  oeoole    should  have   an   eye 
examination,    I   believe   your  association    recommends   that    a 
comolete   eye   examination   and   visual   analysis    should  be 
seriously   considered   at    least   every   other  year.      It    is   true 
that    those   who   wear   glasses    may   not   need   a   change    of   lenses 
that    often,   but   examination   at    regular  intervals    is    definitely 
essential.      The    screening  examination    for  early   signs    of  visual 
impairment    that    is    orovided    for   in    my    bill   will   act    as    a    fore- 
runner to    referral   to  orofessional  oractitioners    for  those   who 
require    such    services. 

When   I   talk   to   a   gathering   of  this   nature — a    grouo    of 
orofessionals--!   always    do    a   little   homework   beforehand   to 
acquaint   mvself  with    the    aims    and   objectives    of  the    prouo , 
and   to   reinforce    my   knowledge    of  the   profession,    its 
oractices,    its    imoact   on   the   Nation's   health,   and   what    it    is 
doing   or  might    do   to    further   the    health    goals    nf  the   Nation. 


*  Address    delivered    at    the    Conference    Luncheon,    The    Mayflower 
Hotel,   Washington,    D.  C.  ,   Thursday,    March   24,    1966 

**Reoresentat  ive    from  Rhode    Island,    U.S.    House    of    Reoresentati  ves , 
1235    Lone-worth   House    Office    Building,   Washington,    D.C. 

31 


But   I    should  note   that,    in   this    instance,    mv  home- 
work  was    a  matter  of   re  acquaintance — a   refresher   course,    if 
you  will.      I   had   delved   deeply   and  at    threat    lenprth    into   the 
field   of   ootometry   in   the   oast    several   years   when   we    were 
working  to   include    schools    of   ootometry    and   ootometric 
students   in   the   Health   Professions   Educational    Assistance 
Act    and  its   amendments. 

I   believe    you   and   I   were   equally    gratified  when  we    won 
our  case,    and  schools    of   ootometry  became   eligible    for  con- 
struction   grants    and   grants   to   imorove   educational  Drogram 
quality;   we   were   equally   gratified  when   students    at    these 
schools   became   qualified   for  benefits    from  the    student 
assistance    features    of  the    legislation — student    loans    and 
Federal   supDort    for  scholarshios . 

To   return   to   my   earlier  statement  :      during  my   "home- 
work"  oeriod,    I    came    again   to   a   little    volume   edited  by 
Drs.    Monroe    Hirsch   and   Raloh  Wick,    titled   "Vision   of  the 
Aging  Patient--An    Ootometric    SymDOsium." 

While    I    was   quite    aware    of  your  orofession's    interest 
in  the   aging  and  aged,    I   had  not    realized  how   far  that 
interest   reached  back   into  time.      Dr.    Henry   Hofstetter's 
introduction,    for  examDle,    reminded   me   that   "Ootometry, 
oerhaDS    longer  than    any   other  orofessional    group,    has 
had   specific   concern   with   agin?:,"    and   traced  that    concern 
back    for  some   500   years.      .And,   while    Dr.    Hofstetter   cited 
the   age    of   40   as   a   clinical  ooint   of  demarcation   between 
young   and  old,    I   was   esoecially   interested  when  he   wrote 
that    "  *    *    *    from  a  ourely   ohysiological  ooint    of  view,    50 
to  55    years    of   age    would  have    been   a   more    logical  ooint    of 
demarcation." 

This    certainly   added   validity   to   my   choice    of  the 
half-century   mark   as   the   age    at   which    our  adult   pooulation 
would  become   eligible    for  the    services   of  our  orooosed 
adult   health  orotection   centers. 

And   Dr.    Vincent  Ellerbock,   writing   about   oartial 
vision:      "It   now   is    aooarent    that    both   cataract   and   glaucoma 
are    subject    to   detection    and   care    and   in    a   great    majority 
of   cases   need  not   oroduce    any    serious    loss   of  vision."      This 
statement    certainly    fortified  my   belief  that   detection — 
followed  by  the    aoolication   of  oreventive   measures — soelled 
out   the   most   practicable   way   to   assure   the    continued  health 
and  well-being  of  our  aging   generations. 

My   reading  oroduced   one    other  olum.      The   value    of  orooer 
eye   care    for  our  older  oeoole   has    rarely  been   exoressed  more 
succinctly   than   by   Dr.    Ethel   Percy   Andrus,   then   oresident   of 


32 


the    American    Association   of   Retired    Persons.      Tn    the    foreword 
to   Drs.    Hirsch    and   Wick's   svmoosium,    Dr.    *\ndrus   noted  in   cart 
"the    increased  orovision    for  eve    care    and  the   early    detection 
and   control   of  eye    disabilities    is    one    of   the    important   trends 
in   the    current  nationwide    movement    for  the    welfare    of  the 
aged.       The    human   need    for  orotectinr  the   eyesitrht    of  the 
elderly    cannot    be    magnified.       Preserving    for   them   their 
vision    opens    for   them  oooortunities    for  mo^e    abundant 
living,    and   so   assures    for  them  wider  dimensions   of  health 
and  enjoyment." 

I   believe   vou    can   understand  more    readily  now  whv   I    am 
oleased  to   aooear  here    today,    and  most    grateful    for  the 
invitation   to   .loin   you. 

I   note    that   this    conference    will    deal   with    the    identifi- 
cation  of   visually    limited  individuals — how  to   serve    not    only 
their  visual   needs,    but   also  their  social    and  economic  needs; 
and  how  to  effect   their  orooer  care.      This    overall    concept,    as 
it    relates    to  obtaining;  treatment    for  the    less    affluent   of  our 
agine-;  citizens,    moves   hand   in  hand  with    that   of  my   bill. 

In    1956,    when   I    recommended   a   White    House    Conference    on 
Aging,    I   said   that    "ae;ing   touches    or  oervades    most   asoects   of 
American   life    today;    urban   and   rural   living;    wages,    salaries, 
oensions,    insurance,    and  other  affairs    of   our  economy;   bio- 
logical   and  osycholoe;ical    fields;    and   civic   and  oolitical 
matters. " 

In   1957,    shortly   after  its   establishment,    the    special 
staff   on    aging  of  the    Deoartment   of  Health,    Education,    and 
Welfare,    stated   the   oroblem   In    a   slichtly   different   manner: 
"We    must   helo    older  oeoole    *    *    *   to  emoloy   better-  the    skills, 
the   exoeriences,    and  the    resources    thev   have    gained   over  a 
lifetime.       To    the    extent   we    succeed    in    meetinp  this    challenge, 
we    shall   have    built    a  tremendous    reservoir  of   strength    for 
the    Nation.      Otherwise,   the    growing  number   of   older  oeoole 
*    *    *   will    become    an    overwhelming   social,    medical,    and 
financial   burden   on   their   children,    the    community,    and   the 
total   economy." 

The   orogress   that   has   been    made    in   the    intervening 
years    is    a   source    of  oleasure    for  all   of  us.      Many   oooortunities 
have   been   afforded    our  older   citizens    for  increasing  their  self- 
sufficiency   and   continuing  their  usefulness   to   the    community. 
And  yet,    the    task   of   deriving  the   utmost    from  their   full  ootential 
remains   a   substantial   one. 

Admittedly,   we    are    doing  a   sreat    deal    to   make    it   oossible 
for  more    of  our  elderly  oeoole    to   live   healthier  and  more 
oroductive    lives.      But    much   more    remains   to   be    done   in   this 
area,    and   it    is    here    that   the    imoact    of  the    Adult   Health 


33 


Protection    Act   will   be    felt.      Only   by   earlv   identification 
and   subsequent    control    of  disease    and  prevention   of  illness 
and   disability   can   we    beo-in    to   keeo   our  adult  oooulation   in 
a  state   of   crood  health   that    will   enable    them  to   sustain  a 
ootential    we    will    find    it   worthwhile    to    tan. 

The   bill   I    have    introduced    is    an    outgrowth   of   an    idea 
I   exoressed   last    fall   when    I   heloed   dedicate    Cranston,    R.I.'s 
first    low-rent   housing  develooment    for  the   elderly.      I    stressed 
at   that    time    the    urgent  need    for   long-term  comorehensive    care 
for  the   elderly — an  entire   program  of  services   to  orovide 
all   the   needs   of  life.      I    called  that    concent    living   care. 

At   about   the    same   time,    on   the    Senate    floor,    Senator 
Harrison   Williams,   of  New   Jersey,    reminded  his    listeners 
that   the    dramatically    increasing  numbers   of  our  aged  and 
aging  population   oresented  a   "growing  oroblem  with   soecial 
sipmificance    for  chronic   diseases."      His   orogram  was 
called  oreventicare. 

Acting  indeoendently ,    but   with  the   same    long-term 
goals    in   mind,    Senator  Williams    and   I   had   come   to  the 
same    conclusion. 

What    we    are   orooosing— I   know   that   most    of  you   are 
aware   that   Senator  Williams  has    introduced   a   similar  bill 
in   the   Senate — is    that   it   be    the    sense    of  the   Congress 
that    "the    Federal   Government   has   a   duty  to  assist   the 
adult   population   of  the    United   States,   oarticularly   the 
aged   and  the    aging,    in  protecting,   maintaining,    and   im- 
proving their  health." 

Soecifically   our  aim  is   to    launch    a   genuine   nation- 
wide  preventive    medicine    camoaign   in   the    form  of   a   $60 
million,    3-year  demonstration   program,    including  training 
and   research,    in  health  orotection   centers.      Having   fought — 
and  to    great  extent   won — the   battle    against   infectious 
diseases,   we    consider  it   most   logical   to    combat   the 
chronic   diseases   with   the    same    kind  of   aggressive,    thorough- 
going and  determined   approach.      Experience   has   shown   us 
that    complete   prevention    can   be    attained   in  many    instances 
and  that   disability,    crippling,    and  premature    death   can   be 
delayed  by  preventive   methods    and  techniques. 

Through   grants,   we   would  encourage    and  assist    the 
olanning,   establishment,    and   ooeration   of  5    regional    and  20 
community   adult   health   orotection   centers;   orovide    assistance 
for  training  the   essential   manpower  that   would  ultimately   be 
involved;    and   assist    in   conducting   research    related  to  the 
centers   and  their  ooeration. 


34 


> 


The   health  orotection    centers   would  make    available    to 
any   oerson   over  50,    on   a   voluntary   basis,    a   series   of  basic 
tests    that   would   detect    abnormalities    in   the    cardiovascular, 
respiratory,    gastrointestinal,    genitourinary,   and  musculo- 
skeletal  svstems,    as    well    as    defects    in   metabolism   and    in 
the    organs    of   soecial   sense. 

The    tests    would   be    administered   by   qualified   technicians 
nurses,    and   other   medical    soecialists,    using   automated  equio- 
ment    caoable    of  oroviding    raoid   and    reliable    results.       These 
results,    available    within    a   matter  of   a    few   hours,    would   be 
referred  to   the    individual's   orivate   physician   or,   where   the 
individual   had   none    or  was    indigent,    would   be    referred   as 
determined  bv    local  oract  itioners  . 

I   want   to    repeat    that    in  every   case    the    results   of 
screening  tests   would  be    forwarded   to   a  practicing  ohysician. 
I    am  emohasizing  this    feature    of  the   program  because    some 
oeoole   who  have    only   scanned   our  orooosal  have   the    mis- 
conception  that    the    centers   are    to   be    diagnostic   and  treatment 
centers. 

This   is   not   the    case.      Where   treatment    is    indicated, 
the    function   of  the    center  staff  will  be   to   assure    that    the 
oatient   is   Drooerly    referred   and  brought   under  a   doctor's 
care.      And   in   those    cases   where   the    screening  tests    reveal 
no    sign   of  incioient    disease,    test    results   will   still  be 
forwarded   to   a  Dhysician,    since    they   will  orovide    a   firm 
basis    for   any    future    complete   physical  examination,    when- 
ever accomolished. 

In   passing,    a  word   or  two  about   the    aDolication    of 
automation   to   health   checkups.      Probably   the   best-known 
program  is   that    of  the   Kaiser-Permanente    fJroup,    ooerating 
in   the    Oakland,    Calif.,    area,   which   has    suoolied  much 
concrete   evidence   of  the    value    and  practicability   of 
automated  preliminary   health   tests.      For  those    of  you  who 
might    like   more    soecifics    on   automation   in  a  health  pro- 
gram setting,    I   refer  you   to    the   published  writings   of 
Dr.    Morris   F.    Collen,    director  of  medical  methods    research 
for   Permanente. 

My    corresoondence    tells   me   that   automated  multitest 
screening  orograms    are   presently    in   ooeration   on   a   limited 
basis    in    Michigan,    Indiana,    and  here    in   the   District   of 
Columbia,    generating   great   interest   because    of  their  ability 
to    discover  ailments    in   aooarently  healthy  oeoole   before    any 
symptoms    make   their  apoearance.      In    a   dozen   other  instances, 
States,    universities,    and   individual    communities    are 
contemplating  use    of  a   similar   technique. 


35 


An   audience    of  this   nature   has   humanitarian   as   well   as 
a  professional    interest    in  oeople   and   their   good  health. 
Because    of   this    double-barreled   interest,    I   emphasize    to   you 
the    imoortance    of   this   proposed  program.      We  have    made 
great   progress   in  advancing  the   cause    of   our  older  citizens, 
but    our  entire    investment    to   date--although   it    represents 
many,    many   millions    of   dollars — although    it   has   broken  new 
oaths   and   added  new  dimensions — will   lose    a   great    deal   of 
its   meaning   if  we   do  not    do   more   to  help   our  aging  poDulation 
to  anticipate    their   golden   years.      We   must    do   everything 
within   our  power  to   make    certain    that    more   and   more    of  our 
citizens    reach   that   period   of  their   lives   with  a   clean  bill 
of  health. 

I   sincerely  believe   that    the   program  we   are    recommending 
reoresents   the    surest   and  most   practical   way   to   accomplish 
this.      Certainly  more    aging  peoole    stand   a   chance   to   do 
so   if  their  medical   histories    reflect    concerted   preventive 
action   against   those    disabilities    that   cause    so   many   of 
them  misery   and   untold   suffering  today. 

There    is    still   another  preventive    angle   that    is    implicit 
in   this    program,    and  that    is   a   human   and   psychological   one. 
Properly  utilized,    this   program  will  orevent   an    incalculable 
number  of  our  aging  citizens    from  entering  into  the    isolated 
and   secluded   type    of  existence    that   has    been   their  portion 
so  often   in  the   past.      On   the    contrary,    by  bolstering  their 
sense    of  well-being,    it    will   help   them  to   add   their   renewed 
vigor   and  exoerience    to  a  host    of  community   projects    from 
which   their  personal   dividend  will  be   better  and   more    sub- 
stantial  lives, 

A   Mew  York  Herald  Tribune   editorial   of  a    few  weeks   back 
stated  that    "only  now   is   it    widely   realized  that   the    health 
of  an    individual   or  a   family    is   not    simoly   a  private   affair, 
that   preventable    illnesses   and   death   due   to   ignorance   and 
neglect   are   a   waste    of  the    Mation's    most   precious    resource- 
its   people."      I    could   not   have    asked    for  a   better  articulation 
of  the   basis    of  my   concern    for   our  aging  people.      And   I   am 
heartened  to    find  that    many   of   our    leading  physicians   have 
expressed  their  agreement   with   our  plan   wholly   in   principle, 
and   almost   without   exception    in   design. 

With  medicare,    we   began   to   apply   the    Golden   Rule   to   the 
golden   years.      Our   proposed   program — The    Adult   Health   Protection 
Act   of   1966--conceives    of  the    years   after   50   as   the   time    to 
make   certain   that    more    of   our   citizens   will   enter  the    golden 
years   in    full   possession   of   their  faculties,   ohysical   and   mental. 
We   consider   it    a    logical   extension   of   medicare. 


36 


I   am  encouraged   by   the    support   that   our  proposal   has 
gained  thus    far.      I    have    great    respect    for  those   who   may 
oppose    it    in   good  conscience.      To  those    who  cry    "creeping 
socialism,"    I   can   only   say   that   every   man    is   due    his 
personal   prejudices.      In   this    regard,    I   believe    all    of 
you  know   that    my  Drejudices   are    in   accord  with   those   of 
President   Johnson,    whose   health   oroposals  this    year   set 
as   the   Nation's    goal:      "Good  health    for  every   citizen  to 
the    limits   of   our  country's   capacity  to  provide    it." 

I   have   no   doubts   as   to  this    country's   capacity   to 
provide    the   health   opportunities   that    the    Adult   Health 
Protection   Act   contemplates.      The   need   for  the   program 
is   urgent;    the    technology   for  the   program   is   at   hand.      I 
am  confident    that    the   Congress— with  the   expressed   support 
of  professional   organizations   such   as   yours--will   make    the 
right   choice. 

1235    Longworth   House   Office    Building 
Washington,    D.    C. 


37 


PANEL   2 

"Serving:  the   Visual   Needs 
of  our  Visually-Limited  People" 

Afternoon   Session,    March   2  4,    1966 

Panel   Chairman   -   C.   EDWARD  WILLIAMS,    0.    D., 
Member,    Committee    on   Aid   to  the   Partially-Sighted, 
AMERICAN    OPTOMETRIC    ASSOCIATION 


****** 


PAPERS   PRESENTED   BY 

Alfred   A.    Rosenbloom,    O.D.  ,    Dean,    Illinois    College 

of   Optometry. 


Ralph   Gunkel,    O.D. ,   National   Institute    of  Neurological 

Diseases    and  Blindness,   National 
Institutes    of  Health,    Public  Health 


Service  ,    U.S. 
Education   and 


Department 
Welfare. 


of  Health, 


Louise   L.    Sloan,   Ph.D.,   Laboratory   of  Physiological 

Optics,   Wilmer  Institute,    Johns 
Hopkins   University. 

Douglas   P.    Wisman,    O.D.  ,    Committee    on   Aid  to   the 

Partially-Sighted,   American    Ootometric 
Association. 


RESOURCE    PANELISTS 

Earl  T.    Klein,    Acting  Director,    Office    of  Evaluation 

and   Reports,    Office    of  Manpower, 
Automation   and  Training,    U.S. 
Department   of   Labor. 

Eugene    F.    Murohy,   Ph.D.,    Chief,    Research   and   Development 

Division,    Prosthetic   and   Sensory 
Aids   Service,    Department    of   Medicine 
and  Surgery,    Veterans   Administration. 


38 


SUBNORMAL  VI 3  TOM  CARS; 
AM  ANALYSIS  0^  CLPIIC  PATTsMTS* 

.. — -    _   —    _   —  _  _  .  .    _    _  _  _ 

Alfred  A.  Rosenbloom,  Jr. ,0.D.** 

A  point  of  view  central  to  this  Conference  on   Aid  to  the 
Visually  Limited  is  our  conceot  that  the  visually  limited  person 
is  first  and  foremost  an  individual.   Like  any  other  person,  he 
oossesses  such  qualities  of  individuality  as  character,  tempera- 
ment, potentiality,  education  and  environment. 

Since  1955  this  speaker  has  been  privileged  to  serve  as 
optometric  consultant  to  the  Chicago  Lighthouse  for  the  Blind. 
The  Lighthouse  program  exemplifies  the  professional  team 
approach  offering  a  wide  range  of  professional  services — 
social,  medical,  psychological  and  optometric.   The  Drogram 
was  designed  to  meet  the  following  objectives: 

1.  To  helo  visually  handicapped  persons  achieve  maximum 
use  of  residual  vision  through  application  of  new  knowledge, 
techniques  and  methods  regarding  low  vision  aids. 

2.  To  increase  the  employability  of  visually  handicapped 
persons  by  helping  them  function  as  effectively  as  possible. 

3.  To  stimulate  cooperation  among  specialists  in  allied 
fields  and  to  coordinate  state  and  community  services. 

To  date  over  1,000  patients  have  been  examined  in  this 
program.   With  rare  exceptions  each  patient  was  legally  blind. 
As  a  necessary  prerequisite  to  accepting  each  patient  for  the 
subnormal  vision  examination,  a  medical  report  form,  including 
a  thorough  diagnosis  of  the  ocular  pathology,  was  completed 
by  the  referring  or  attending  ophthalmologist.   Upon  completion 
of  the  subnormal  vision  examination,  all  findings  and  recommended 
corrective  procedures  were  shared  with  the  attending  ophthalmologist. 
Even  a  brief  report  of  what  we  found  in  studying  these  1,000 
patients  offers  valuable  insights. 


*Summary  of  a  paper  to  be  published  in  the  American  Journal  of 

J  i      ii  -i  ■  i  ii 

Opt  omet ry 

**Dean,  Illinois  College  of  Optometry 

39 


We   divided  our  study   into   five    categories:       (1)    a 
review   of  the    success   achieved;    (2)    the   kinds   of  ocular 
pathology  diagnosed;    (3)    the    types    of   low  vision   aids 
prescribed;    (4)    a  brief   report    on   psychiatric   evaluation 
of  selected  patients;   and    (5)    a   follow-up   summary   of 
results   achieved. 


Degre.e_of   Success   Achieved 

In   analyzing  the    degree  "of   success   achieved,    we    found 
that  about    75   percent   of   the    first    1,000  patients   studied 
could  benefit    from  the   prescription   of   low  vision   aids; 
7  percent   of   these,    however,    did  not    accept   the    visual 
correction.      Our  study   revealed,    also,   that   a  significant 
number  of  this    7  percent    had   suffered  a   blinding  incident 
or  disease.      Mo   low  vision   aid  was   indicated   or  prescribed 
in  about   25  percent    of  the    cases. 

We    found   that    38   percent   of  the   patients   were    diagnosed 
as   congenitally  blind  and  62   percent   adventitiously  blind. 
Although  congenitally   blind   individuals   were    fewer 
in  number,    for  the   most   part   they  had  greater  success   with 
low  vision  aids.      The    greater  incidence    of  success   may   be 
the    result    of  the    fact   that   congenital   conditions   resulting 
in  subnormal   vision  produce   a   greater  degree    of   residual 
vision   and,    consequently,    greater  potential   for  success. 
The   markedly  smaller  number  of  unsuccessful  patients   in 
the   congenitally   blind  category   suggests  that   educational 
and  motivational   factors   are    important   considerations. 

The   number  and  age    range    of  patients   and  the   percentage 
of  success   and   failure   within  each   category   was   also  studied. 
The   percentage   of   success   was    greater  in   the   age    range    from 
11  to   60.      Almost    HO  percent   of  our  patients   were    60   years 
of  age    or  over.      Notwithstanding  the    debilitating  effects 
that   may   occur  with  age,    the   number  of  patients   who   benefited 
in   the   age    range    of  6l  to   8l  was   more   than   twice    the  number 
of  unsuccessful   cases. 

In  evaluating   the    results   with   this    older   group   it    must 
be   remembered  that   their  needs,    adaptive   capabilities, 
interests   and  physical  problems    in   some    cases  produced 
limitations   which  were   distinct    from  their  visual  problems. 

Approximately  20  percent    of  the   patients  were   21  years 
of  age    or  under.      Where    sufficient   residual   vision   was  present, 
patients   in   this    age    group   enjoyed  an  extremely   high   degree   of 
success.      Probably  because   of  their   great   visual  needs,    high 


M0 


level   of   motivation  and  adaotive    capacities,   this    student 
age    group    should  be   among;  the    best    candidates    for  visual 
rehabilitation. 

Success    in   using  subnormal   vision   aids   was    also   assessed 
in   relation    to   the    soan   of   time    when   the   patient    sustained 
the    visual   loss.      We    found  that   patients   who   have    been    legally 
blind   for  ten    to    fourteen    years  prior  to   subnormal   vision 
examination   were   the   most    successful   individuals   with    low 
vision   aids.      Over  68   percent    of  the   patients   who   had   been 
blind   less   than    two   years   were    also   recorded  as   successful 
oatients.      This    finding   is    in   sharp    contrast   to   the    frequently 
heard   assumption    that    newly   blinded   individuals    are    frequently 
unprepared,   emotionally,    to   accent   marked   visual    impairment 
or   to   attempt    the    use   of   a   visual   aid   that    only   oartially 
restores   visual    function. 

The    relationshio    between   the   patient's    educational   back- 
ground and  his   performance    with    low   vision  aids   was    studied 
in   a    group    of   155   oatients    randomly   selected   from  a   total 
copulation.      As   expected,    those   oatients   who  had   the    greatest 
amount   of  education   achieved   the   highest   oercentage    of 
success. 

An   analysis   was   made    of  the   effect   of  occupational 
status    upon    the   patient's  performance    with  the    low   vision 
aid.      Those   who   were   employed  or   in   student    status    demon- 
strated  a   higher  percentage   of  success    than   patients   in 
other  categories.      Since    the   population    included   a   higher 
percentage    of  elderly  persons,    it   was  necessary   to   distinguish 
between    retired  and  unemployed  persons.      In   both   of  these 
categories   approximately   two-thirds   benefited. 

Kinds    of  _Ocular   Pathology 

Examination   of  the    ocular  pathology   responsible    for  the 
visual    loss    revealed   that   choroidal   and/or  retinal   changes 
occurred  with  the    greatest    frequency   in   over  50   percent   of 
the    patients    while    conditions    of   the    cornea   were    least 
frequent    (about    5    percent).      Approximately   one-sixth   of 
the    population    incurred   diseased   conditions    of   the    optic 
nerve    while    another  25   percent   manifested   congenital 
anomalies,    congenital   or  acquired   amblyopia  and  miscellaneous 
ocular  pathologic   conditions. 

Within  the    largest   pathological   type — choroidal   and/or 
retinal   pathology — approximately    75   percent   of   the   oatients, 
along  with   about    60   percent    of   the   oatients   whose    diagnosis 


41 


is   orimary    ootic  nerve    atrophy,    could  be    corrected  to    8 
ooint   type    (equivalent    in    size    to  newsprint)    or  better 
with   the    aoprooriate    visual   aid.      The    fact    that    greater 
success   was   achieved   in    such   cases    seems   primarily    a 
function   of   the    amount    of   residual   vision,    rather  than 
the   particular  tyne    of   ocular  pathology.      Patients   with 
central   vision    loss   and  normal   or  near  normal   visual 
fields   were    more    amenable    to    successful   correction   with 
low  vision   aids.      When   we  plotted   central   and  oerioheral 
visual   fields   of   some    100   unselected  patients    on    the 
Lloyd's   stereo-campimeter,    we    found   no   significant 
relationshio   between   the    successful  prescriotion    of   a 
subnormal   vision    aid   and   the   nature    and  extent   of   the 
central    or   the   oerioheral    fields    of   vision. 

The  .Type    of   Subnormal  Vision   Aid   Prescribed 
When    considering   all   patients   prescribed   successfully 
with    low  vision   aids,    we    find   that    over  65   percent    were 
orescribed  either  a   high  plus    reading  addition  or  a 
microscopic    lens   providing  5X   to    12X  magnification.      The 
near  vision  of   over   80  oercent    of  these   patients   was 
improved  by   the    aopropriate    correction   to    the   ooint   where 
magazines   and  newsprint   could   be    read.      About    10   percent 
of   the    aids   prescribed   involved   the    use    of   fixed-focus 
hand  magnifiers.      Selection   of  this    aid   was    often    dictated 
by   senile    changes,    occupational  preferences   or  use   as    an 
interim  or  auxiliary    correction. 

The    site    of   the    visual   imoairment   was    a    significant 
factor   in   determining  the    type    of  visual   aid  prescribed. 
Contact    lenses   proved  particularly   valuable    in    (1)    cases 
involving  corneal   irregularity,    (2)    cases   where    improved 
visual    function   was   possible    with    contact    lenses    as 
compared  to    the    spectacle    lens    counterpart    (e.g., 
aphakia,   high  myopia,    high  hyperopia)    and    (3)    as    a 
limiting  aperture    in    cases    involving  pupillary   irregularities 
and  media   involvements.      Few  patients   could   successfully 
adapt    to   a   contact    lens-telescooic    system,    a  procedure 
that   presents   a  number   of  visual  problems   and   requires 
the    greatest   amount   of  professional   judgment,    insight 
and  clinical   skill. 

Telescopic    lenses,    often   of   the    ready-made    type,   were 
prescribed   in   about    10  oercent    of   the    cases. 


42 


Psychiatric   Evaluation    of  Selected  .Patients 
Another  aspect    of  the    Lighthouse-  study   was   a   consideration 
of  psychological    factors   that   may    lead  to   acceptance    or 
rejection   of   low   vision   aids.      In   an   attempt    to   understand 
the   personality   of  oatients   applying   for  subnormal   vision 
aid   services,    the    consulting  Dsychiatrist    interviewed  50 
consecutive   non-selected  oatients. 

Capabilities,    achievements   and   reactions   to   life 
situations   as    revealed   in  the    interviews    of  the    apDlicants 
clearly   indicated   that    some   patients   had   serious   emotional 
problems.      In    general,    three    grouDS   of  patients   were 
identified.      The    first    group,   about    68  percent   of   the 
population,    were   patients   who  eagerly   accepted   the 
benefits   of  this   professional   service.      Only   four   of 
the    35    applicants   in  this    group   had   severe   emotional 
problems   that   might   require   osychiatric   care. 

The    second   group    constituted  about    10  oercent    of 
the   patients  who  could   derive   help    from   a   low  vision   aid 
but    directly   or  indirectly   refused  to   accept   either  the 
adaptive    training  or  the    recommended   correction.      Analyses 
of  this    group    showed   individuals   who   at    some   time    in 
their   lives   had   suffered  emotional   trauma  which  produced 
suspicious   and  hostile   attitudes. 

The   third   group — about   24  percent — had  disabilities 
which   could  not    be    improved  by   low  vision   aids. 

Psychiatric  evaluation   of  the    third   group    showed 
several   instances    of   severe    mental   illness;   six 
patients   were    in   deep   emotional   depression   and  three 
were    frightened,    anxious   and  disturbed.      Only   three 
patients   in  this    third   category   seemed   free    of  oroblems 
to   which  they   were    inaporopriately   reacting.      As   a 
group   o'f  these   patients   were   not   accepting  their 
blindness ;    they   apoeared   to    cling  unrealistically   to 
the   hope   that    some   new  medical   treatment   might    restore 
their  vision.      One    significant    finding  which   emerged 
from   these    deoth   interviews   was    the   need   for  counseling 


43 


to  bring  about   a  osychologically   sound  acceptance    of 
blindness,   especially   among  patients   suffering  a   recent 
visual   loss. 

An  _E valuation   of  Results  :. ^  .Progress    Reoo.rt    Data 
A    final   aspect   of   this    reoort    is    a    summary   of   our 
findings   concerning  the   extent    to   which   a  oatient   con- 
tinued  to   use   his    low  vision   aid   and    found   it    a   useful 
oart    of  his   everyday    life.      Since    the    beginning  of  the 
Lighthouse   program  aporoximately   one-third   of   the 
patients    (about    335   oatients)    were    re-examined   or 
interviewed  between    six   months    and   one    year  after 
the    subnormal   vision   aid  had   been   prescribed  and 
dispensed.      Only  oatients   who   had  their   low  vision   aids 
for  a   minimum  Deriod   of   six  months   were   evaluated.      In 
some    cases  the    data   were   based  on   a   carefully   organized 
follow-up   questionnaire   Dreoared    for  use   either  as   a 
telephone    or  mail   inquiry.      Each   case    was   carefully 
evaluated  and  placed   in   one   of  three    categories. 

Approximately   55   percent    of  the   patients   were 
regarded  as   highly    successful.      This    group    included 
patients   who   wore   their   low   vision   aids   constantly, 
performed  a   variety   of   visual   tasks    from  day  to   day 
and  were   highly  enthusiastic   about   the    results. 

Another   25   percent   were   /judged   moderately 
successful.      Such   patients    did  not    wear  their   low 
vision   aid  constantly  but    reoorted  using  it    at 
regular   intervals    for   specific   and   important   visual 
tasks. 

The   20   percent    considered  unsuccessful   were    one 
of  two   types.      Some   Datients   may   have   been   able    to 
continue    using  their   visual   aid,    but    senile   changes, 
poor  health  or  other   factors    reduced   or  seriously 
limited  the    use    of   or  enthusiasm   for  it.      In    other 
cases,    patients   seldom  wore    the    aid   or  expressed 
any   interest    in   returning   for  re-examination.      From 
this    survey   it    is   evident   that   about    SO   percent    of 
the   patients   examined   or   interviewed   on    follow-up 
studies    are    using  their  aids   with    reasonable    regularity 


44 


and   success.      This   program  is    but    one    means   whereby 
we   in   optometry   are    facing,    indeed,    welcoming,    the 
challenge    of  meeting  the    needs   of   visually   impaired 
children   and   adults. 


32  41   Michigan   Avenue 
Chicago,    Illinois 


45 


VISUAL  ASPECTS 
OF  OCULAR  PATHOLOGIES 

-*  - ■ 

Ralph  Gunkel* 

3y  way  of  introduction,  I  might  say  that  I  am  associated 
with  six  ophthalmologists  at  the  National  Institutes  of  Health. 
My  work  consists  mainly  of  osychophysical  tests,  including 
dark  adaptation,  "retinal"  thresholds,  color  vision,  certain 
special  types  of  visual  field  tests,  and  examination  of  patients 
with  subnormal  vision.   I  see  many  patients  manifesting  uveitises, 
macular  degenerations,  glaucoma,  and  certain  types  of  cataract. 

N.I.N.D.B.'s  point  of  view  is  that  anyone  who  is  not 
correctible  by  ordinary  means  to  20/20  vision  is  visually- 
handicaDped,  whether  he  knows  it  or  not.   We  also  say  that 
anyone  who  has  a  near  point  of  clear  vision  greater  than  14 
inches,  is  visually  limited.   Ordinarily,  the  latter  can  be 
corrected  with  simple  olus  lenses,  but  if  for  some  reason 
the  lenses  cannot  or  will  not  be  used,  the  oerson  is  visually 
handicapped. 

Some  peoole  have  severely  restricted  visual  fields  even 
though  their  acuity  is  normal.   If  their  state's  Department 
of  Motor  Vehicles  requires  a  larger  field  of  vision  than  they 
have,  they  are  visually  limited,  and  this  type  of  limitation 
is  not  amenable  to  complete  correction. 

In  general,  we  must  say  that  visual  limitation  is  not 
necessarily  related  to  loss  of  functional  cones,  in  the 
central  retina,  but  rather  to  our  ability  to  meet  the  visual 
requirements  we  have  imoosed  on  ourselves,  or  society  has 
imposed  on  us.   Occasionally  I  see  peoole  with  20/50  vision 
who  are  unaware  of  any  nroblems;  then  sometimes  peoole  with 
20/20  vision  conrolain  bitterly  that  they  cannot  see  the  fine 
details  that  they  used  to  enjoy. 

I  find  that  classifying  subnormal  vision  according  to 
cause  sometimes  helps  in  a  decision  as  to  how  or  whether  it 
can  be  helped.   Lack  of  color  Derceotion  is  certainly  one 
tyoe  of  visual  limitation.   Total  achromatoosia  is  not  as 
rare  as  one    might  think,  and  it  is  frequently  confused  with 
macular  degeneration.   The  rod  achromat  has  no  color  perceotion 


*0. D. ,  Ophthalmology  Branch,  National  Institute  of  Neurological 
Diseases  and  Blindness,  U.S.  Deoartment  of  Health,  Education  and 

Welfare . 


'4  6 


and  usually  has  acuity  less  than  20/70.   He  is  very  uncomfort- 
able in  bright  lights,  sees  better  in  twilight,  and  may  have 
nystagmus.   A  simole  dark  sunglass  may  be  a  great  help  for 
his  vision,  or  it  may  be  made  into  contact  lenses.   Some 
achromats  orefer  a  dark  red  glass  or  contact  lens,  although 
it  does  not  look  red  to  them. 

The  cone  achromat  has  Derfect  visual  acuity,  so  needs 
no  visual  aid.   His  lack  of  color  oerception  cannot  be 
helped,  so  he  must  ad.iust  to  it. 

The  dichromats  are  certainly  visually  limited,  and  this 
is  sometimes  a  oroblem,  particularly  in  young  school  children. 
They  cannot  be  made  to  discriminate  colors  normally,  but 
sometimes  they  can  be  helped  psychologically. 

Albinos  have  a  similar  oroblem  to  the  rod  achromats, 
and  for  them  a  dark  neutral  density  filter,  either  in  classes 
or  contact  lenses,  is  a  visual  aid.   Fortunately,  they  usually 
have  normal  color  vision. 

In  macular  degenerations  or  central  uveitis  there  is 
always  a  oroblem  of  central  scotoma  with  resulting  sub- 
normal vision.   In  general  the  aim  is  to  give  a  corrective 
device  which  will  give  a  retinal  image  large  enough  to 
extend  outside  or  around  the  scotoma.   Dr.  Sloan  will  go 
into  this  at  greater  length. 

Retinitis  oigmentosa  is  a  very  common  cause  of  visual 
imoairment  and,  tyoically,  orogresses  in  SDite  of  anything 
that  is  done.   Usually  central  vision  remains  good  in  bright 
illumination  for  many  years,  so  special  lighting  must  be 
considered  a  visual  aid.   The  constricting  field  cannot  be 
helped.   The  cataracts  which  frequently  accomoany  retinitis 
oigmentosa  can  be  removed,  allowing  more  light  to  enter  the 
pupil  and  enhancing  vision  for  a  time. 

Snlargment  of  the  ouoil  also  helps,  but  with  a  five 
degree  central  field  it  is  very  difficult  to  imorove  central 
vision  if  it  has  begun  to  deteriorate. 

In  the  field  of  acquired  limitations  we  could  list 
traumatic  cataract,  which  is  a  problem  for  the  ophthalmologist, 
as  is  keratitis.   Some  tyoes  of  corneal  degenerations  of  keratitic 
origin  are  beautifully  corrected,  visually,  with  contact  lenses, 
but  this  is  a  delicate  matter. 

Retinal  detachment  is  another  acquired  condition  which 
frequently  causes  visual  limitation.   This  must  just  be  treated 
surgically  by  either  electro-thermal  or  ohoto-coagulation , 
but  it  is  very  difficult  and  the  outcome  is  questionable.   '-/hen 
the  detachment  has  become  Dhysically  stabilized,  the  optometrist 
may  be  asked  to  help  in  adaoting  a  visual  aid.   Dr.  Sloan  will 
tell  you  much  more  about  these  aids  than  I  can. 

lethesda,  Maryland  2001'4 
47 


RECENT   ADVANCES 
IN   LOW  VISION    CARE 

Louise    L.    Sloan* 


I  was   asked  to  talk   about   recent   advances.      Those    I 
am  going  to   discuss    are   based  on   my   own  work.      I    am  talking 
on   a  very   simple    topic,    namely   how  best    to   give   useful 
reading  vision  to   the   patient    classed    as   having  subnormal 
acuity.      In   most   cases    this    assignment  becomes    one    of 
providing  the   means   whereby   the   patient   can   read  a 
newsoaper  at   a  reasonable   speed. 

First,    I   should  like    to  tell  you   about   a  new  soecial 
reading  card   for  testing  these   patients.      Our  laboratory 
found  that   acuity   for  isolated  capital   letters    is   not   a 
good   indication   of  the   power  of  the   magnifier  needed  by   the 
patient   to  permit  him  to    read   ordinary   print   with  ease.      More 
useful   information   is   given  by  tests   using  continuous   text, 
in  graded  sizes,    viewed   at    a   fixed   distance;    40   centimeters 
for  the    cards   we   use. 

The    smallest   print    used   in  these    cards   is   what    we 
call    1M,   equivalent    to   ordinary   reading  matter   such   as 
newspapers,    books   and  so  on.      Others   are   multiples    of   1M. 
If   4M  print    is,    for  example,    the    smallest    read  easily   by 
a   given   patient   at    40    centimeters   then  to   read   1M  orint 
he   must  hold  it  at    1/4   the    standard  distance    (i.e.,   at 
10   centimeters).      The   presbyope   will   need  a   10D   add  to 
read  at   this    distance,    instead   of  the    2.50    add  needed   to 
read   at   the    conventional   distance    of   40   centimeters. 
Particularly   for  presbyopes    given   high   reading;  adds   in 
spectacle    form,    there    is    a  close    relationship   between   the 
actual  powers  prescribed   and   those   predicted  by   use    of  the 
reading  cards. 

There   have   also  been   advances    in   types   of  magnifiers 
prescribed.      At    one   time   everyone   was    given  a  telescopic    lens 
for  distance   with   a  reading  cap    (high  plus  sphere)    for  near. 
In   these    compound  lens   systems,    the   higher  the    add,   the    greater 
the    magnification.      A   2X  telescopic  with   a  +10    cap    gives,    for 
example,   the    same    magnification   as   a   simple    +20    add.      Critical 
depth   of   focus   is    also  the    same.      The   working;  distance    is    10 


*Ph.D. ,    Laboratory    of  Physiological   Optics,   Wilmer 
Institute,    Johns   Hookins   University 


48 


centimeters    for  the    telescopic   combination,    5    centimeters 
for  the    simple    +20   sph.      However,    the    field  of   view  of   the 
simple    lens   is   aooroximately   twice    that   of  the    telescopic 
combination    and  this   orobably  explains   why  the    simole    lens 
is    commonly   preferred  by  patients.       (Cost,   weight   and 
appearance   also   are    factors.) 

Many   different   types   and  powers   of   high  adds    are   now 
available    in   single    vision    or  bifocal    form.      Some    of  bifocals 
are   not    "adds"    in   one    sense    as    they   are    inserts    in  which  the 
power  is    independent   of  the    distance   prescription. 

Some   patients    discover   for  themselves    that    an   inexpensive 
jeweller's    loupe    can   serve    as   a  high   add.      These   are    often 
useful    for  home   trial  before   giving  a  permanent  prescription. 
A   loupe    can   also  be   prescribed   for  temporary   use,   when  vision 
is   expected  to    change   in  a  short    time. 

Many  patients,   particularly  the   elderly,    cannot  use 
headborne    reading  aids.      They   cannot  hold  the   book  steadily 
enough  at   exactly  the   correct    distance    required   for  a  clearly 
focused  image.      They  therefore   try   all   sorts   of  "external" 
magnifiers    and,    by   luck,    can   sometimes    find  a  stand  magnifier 
of  the   proper  strength   which  makes    reading  possible. 

Stand  magnifiers   are    those   which   rest   on  the   page,    so 
that    it   is   easy    for  patients   to  maintain  the    critical 
object-to-lens   distance   needed  to   keep   the   print   in  focus. 
(They   are   often   confused  with  hand  magnifiers.      The    latter 
are 
of  ma: 
jewe: 
returned  if  not   satisfactory. 

There   are   two   general   groups   of  stand  magnifiers: 
(a)    a  low  power  magnifier,   used  with   the   eye    at   a  distance 
from  the   lens;    and    (b)    a  high  power  magnifier  which   requires 
that    the   eye   be   close   to  the    lens. 

Many  stand  magnifiers    are   unsatisfactory  because   the 
lens   barrel   cuts   off  the    light.      The   Sloan   series  have    a 
wider  range   of  powers   and  are   cheaper.      Some   standard 
magnifiers   are    intended   for  use   in  a  spectacle    frame, 
but    can  be   used  separately   as   a  stand  magnifier. 

There    are   several   difficulties   in   giving  other  than 
spectacle    reading  aids  which   account    for  the    fact   that    they 
are   used  very   little.      For  one   thing,    they   come    from  many 
manufacturers.      Some    of  the   trade   names    are   Eze-Rede,   SeeRite, 
Handimag,    Optivisor,   Telesight,    etc.      Also,    there    is   no 
consistent    system  of  rating  the    magnification  of  these   devices 

49 


Recently  we   prepared  a  handbook   at  the    request   of  the 
National   Society   for  the    Prevention   of  Blindness.      It   lists 
recommended   devices   and   rates   them  in  accordance   with   the 
M   level   of   reading   vision    for  which  each    is   suitable.      It 
also   gives    other  pertinent   optical   data,    sources   of  supply, 
so    forth. 

Our   shop   man   is   now  working  on   the    development    of   a 
test   kit.      It   will   include    all   the   essential   items   in  two 
portable   boxes.      Each   magnifier  has    a  code   number  and    fits 
into   its   own   hole    in  styrofoam. 

The    greatest   need  at   the   present    time    is    for  adequately 
equipped   clinics   in  each   city  with   trained  personnel 
qualified  to   prescribe    the   aids,    teamed  with  experts    in 
solving  the   economic,   medical   and  other  problems   of  the 
patients. 


Baltimore,    Maryland     21205 


50 


QUESTION   DIRECTED  TO   DR.    SLOAN:      How   great    is    the   need 
for  training  the    patient   to   use    the   part   of   his    retina   having 
the   best   visual    function? 


DR.    SLOAN:      When    I   started  out    I   was    interested   in 
developing  methods    of  training  the   patient   to   read  with 
a   magnifier.      Much   to   my   surprise    I    found   that    as   soon   as 
they  were   orovided  with   the    required  amount   of  magnification 
they   were    immediately   able   to   read  newsprint.      When   they 
came   back    for  a   recheck   there   was  no  evidence    of   imorovement 
as   a   result    of  oractice   with   the    magnifier  and  no   indication 
that   they   could   get   along  with    less    magnification   than   they 
required  at   the    time    of  the    first   examination. 

Consequently,    I   do  not   believe   that   elaborate    training 
procedures    are    a  necessary  part    of  orescribing   reading  aids. 
It    is    true    that   the    elderly  patient   occasionally    forgets 
what   he    was    told  about   how  to   use   his   magnifier  and  has   to 
be    shown   again   on   his    second   visit.      At    the    first   visit, 
therefore,    it    is    advisable   to   instruct  now  only   the   oatient 
but   also   other  members    of  his    family,    who   are    with  him,    in 
the   proper  use    of  the   magnifier.      With   the   exception    of 
this   sort   of   instruction   I    do  not    find   any  need   for  elaborate 
training  procedures. 

We   do,    of   course,   have    some    failures,    i.e.,    patients 
who   require    such  high  magnification   that    reading   is   not 
worth   the   effort.      Perhaps   after  training,    some    of  this 
group   might   accept    a   reading  aid,    but    I   think    it    is   very 
unlikely. 


51 


VISUAL   DEVELOPMENT    IN 
SEVERELY  VISUALLY -LIMITED    CHILDREN 

Douglas   P.    Wisman* 


The    subject    that    we  have    chosen   is    one    in  which   we 
have    found  a   great    deal   of   satisfaction.      We   practice    in 
a   town   of  two  thousand  people.      A   great  percentage   of   our 
practice    is   in   the    visual   training  of  children, 
vision    from  a   "sequentially-learned-skill"   point 


We  train 
of   view. 


We   still   don't   know  enough  to   take   care    of  all   the 
problems   of   children    in   this    field,    but   we   are    going  to 
speak   of  the    opposite   end   of  the    spectrum   from  that 
covered  by   Dr.    Sloan's   presentation.      She   spoke    of  the 
older  person   and   we'd   like   to   concern   ourselves   with 
the    youngster. 

For  years,    the    fields    of   optometry   and   ophthalmology 
devised  all    of  their  testing  and   treatment    for   the   mature 
adult.      The   child  was   handled  as   a  miniature    or  pocket 
edition   of  the   adult.      It   seems  that    in   just   recent   years, 
we   are    beginning  to   think   of   children  as    growing  individuals, 
constantly  changing. 

From  this   point    of   view,    the    concept    of  visual 
development   adds    a  new  dimension   to   all   of  the   activities 
of  vision   care.      Its   diagnosis,    supervision,   education   and 
re-education   are   as   different    from  conventional    visual   care 
as   day   is    from  night.      The   concept   does  not   abandon   any   of 
those    standard  methods   of  examination   and   measurement   which 
are   based   on   physical   and  physiological   optics.      It   does, 
however,    Incorporate    a  much   wider   ranging  battery   of  tests 
and   treatment   programs,    including  preventive    objectives. 
Developmental   vision   care    is    very   much   related   to   the 
school   and  home,   particularly   the   home.      Our  thinking 
parallels   closely   that    of  Dr.    Arnold   Gesell,    when   he    stated 
that    vision    ".    .    .may   become    a   key   to   the    fuller  under- 
standing of  the   nature    and  needs    of   the    individual   child. 
He    sees   with  his   whole    being,    and  eye   care    involves    child 
care."      In   the    conservation   of  these,   particularly    in   the 
young  child,    visual   care    goes   beyond  the    detection  and 
correction   of  the    refractive   error. 

About   twelve    or   thirteen   years   ago,   the   Lions   Clubs, 
in   their  vision   conservation   program,   evolved  a   project 
known   as  the    "Winter  Haven   Lions   Story"    in  which    they   put 


*0.D.  ,    Member,    American   ODtometric   Association   Committee    on 
Aid  to  the   Partially-Sighted. 


52 


some   of  these   principles   of  motor  development   to  very   good 
use.      They   use   procedures    borrowed   from  a  number   of  disciplines 
to   teach   adequate,    visually   controlled  and  directed,    gross 
movement   patterns   of  activity.      Use    is   made    of   such   things 
as   balance   boards,    sloped  and   standard  walking  rails,    jump 
boards   and   other   similar  materials.      These   are   powerful 
techniques   in  which   we   closely   control  the   oatients' 
visual  environment    as  they   proceed  under  the   program. 

The    results   have    been   rather  promising.      We  have   had 
some   children  who   were   certified   legally   blind.      Our  tests 
showed,    as   you  might    suspect,    gross   motor  inadequacies. 
At    first    just   as   an  experiment    and   later  with   the    increasing 
confidence   born   of   success,   as   a   matter   of   systematic    routine, 
we  have   put   them  into   some    of   these    visually-directed   gross 
movement   programs.      We   had   one    four-year-old   who,    after 
about    two   months,   was   able   to  point   out    and   react   to,    for 
the    first   time,    clouds    in   the    sky    and   the    walls   and  the 
ceiling  and  the   physical   surroundings   of  his    room.      This 
was   a   rather  dramatic   change    for  the   parents  and   the   child! 
We   have   had  a  number   of  patients   who  were    in  the    severely 
limited  vision  area   imorove   to   20/100   or  better  without 
alterations   in    their   lenses. 

This    doesn't    mean   one   throws    out   the    regular  orescriptions 
or  even    subnormal   vision   corrections.      What   we   are    saying, 
however,    is  that   in   special   work  with   these   youngsters 
and  with   young  adults,   we    are    able   to   give    them  a   fuller 
appreciation   and   utilization   of  their  visual  environment 
than   they   had   up   until   the    time    this   tyne    of  training  was 
given   them.      So,    basically  we    feel   that    this    work  has    a   very 
significant   place    in   the    care    of  visually-limited  oeople. 
It    is    an  area  we  probably   have    overlooked   as  we  have   been 
too   concerned  about    getting  standard   resolution   and 
about   which  type    of   lenses   to  prescribe.      We   have   not    seen 
the    forest    for  the    trees. 

We   would   like    to   go   back   and   take   a   look  at   some   of  the 
visual   develoomental   aspects    of   these    little    children   because 
most    of  them  have    been   denied   just   the    gross   movement   patterns 
that    are    the    birthright    of   the   tyoical  child.      Our   amblyopic 
patients   have    resoonded  very  nicely   to  this    type    of  work  in 
which  we   follow   a  progression    from  gross   motor  skills   to   fine 
motor   skills, then   to   hand-eye    relationshios ,    followed  by 
ocular  motor  skills  training.      Only   after  we   get    them  up 
to   "passing"    in  these   areas   does   it    seem  that   standard 
ODtometric  orocedures    take    on   full   value    for  these    individuals. 


53 


It   is    our  experience    that   many   severely-limited  people, 
children  particularly,    can   be  helped   if  given  a   full  visual 
development   evaluation   and  proper   supervision    of  environmental 
factors   in  their   training  procedures. 


124    South   Main   Street 
Woodstock, Virginia     22664 


54 


QUESTION    DIRECTED  TO  EARL  T.    KLEIN*:      How    can   the 
op  tome  trie   understanding  of  his    visual   skills   be    trans- 
lated  into   an   understanding   of  the   oatient's   vocational 
skills? 


DR.    KLEIN:      The   question   nosed   in    our  discussion    p;rouo 
was   how  to  translate    into  vocational   terms   the    ootical 
measurements   of  the   individual,    taking   into   account   any   train- 
ing in   visual   skills   he   may  have   been    given    and   various    aids 
which   may   have   been   nrovided   to  make    accommodations    for  visual 
losses.      The    residual   vision,    often   "  compensation" ,    is    an 
important    factor  in    determining  what    .-Jobs   he   can  oerform 
caoably   and  safely. 

It   is    apoarent    that   the   matching  of  a  worker  with   a 
suitable    .-fob    cannot   be   based   on   the    individual's    visual 
skills   alone.      All    of  his    abilities    must  be   considered. 
With  the   visually   limited  person,    as   with   anyone  else,    the 
first    assumption   to  be   made,    as   noted  by   Dr.    Rosenbloom, 
is   that   he   is    an   individual,   a  whole   oerson.      He   may    lack 
certain  visual   functions   but   he   may  be   a   very   good 
speller  or  a  pretty   good  mathematician   or   a  ooor  sportsman, 
and   so    forth.      In   short,   he   is    a  unique    individual. 

Once   the   individual's   caoacities    and   capabilities    are 
identified,   the   next    steo   is    to   relate    them  to   the 
occupational   matrix   of  the   world   of  work  which   comorises 
23,000   distinct    occuoations.      These    occupations    fall   into 
groups   based  upon   the   mental   and  physical   demands   thev 
make    upon   the   worker.      In   matching  worker  and    1  ob ,    the   re- 
sidual    abilities,   including  residual   vision,    are    stressed 
rather  than   the    visual   loss.      The   U.S.    Department   of   Labor 
has    worked   for   the    last   25    or  30   years   at    analyzing  all 
the    occupations   in  the   American  economy   and   cataloguing 
their  requirements.      The   most   recent    revision   of  , the   Dictionary 
of  Occupational   Titles    categorizes    jobs    in   basic   terms    rather 
than   socio-economic   terms    for  ourooses    of  classification. 
These   basic    terms,    or   factors,    include    the   aptitude    require- 
ments  of  the    jobs,   the   educational   requirements,    tempera- 
mental  demands,    and  the   ohysical   requirements,    including  the 
visual   demands.      This   system  is    very   useful  when   anolied   to 
,1ob   olacement    or   selection    for  training   of  oersons   who   are 
visually  handicaooed. 


*Actine;  Director,    Office    of  Evaluation    and   Reports,    U.    S. 
Deoartment    of   Labor,    Office    of  Manpower,    Automation,   and 
Training. 


55 


Once    the    cytometric   measurements    are    made,    they   must 
be    translated   into    functional   terms    and   then    related  to  the 
requirements    of   different    1obs.      While    visual  oro^iles    of 
1obs   have   been    developed   in    a   crross   sense    through   this 
occuoational   classification    structure,   they    are   orobably 
not    fine   enough    for  ultimate    usefulness    in    selection    of 
an   individual   for  a   field   of  training   or   for  a   .1ob.      I 
think,   however,    it   is    a   good  beginning  and  suggests    a 
starting  Doint    for   further  study   on   the  part    of  an 
association    like    this   to   determine   what   the   aoprooriate 
oatterns    of  visual   skills    are    for  various   tasks. 

Another  technique,    in    addition   to   simoly    visual 
measurements,    is    to   subject    a  client    to   samole   work 
situations,    and   actually   observe   how  well   he    does. 
This    gives   you   also    a  measure    of   the    total    functioning 
of  the   individual,    rather  than    lust   a   measure    of  his 
visual   caoabilities .      This   needs   to  be    considered   as 
another  possibility   and  oerhaos    it    could  be    done    in 
some   kind   of  exoerimental   situation    designed  to  oroduce 
standardized  work   samoles,   each   of  which   had   its   tyoical 
visual  profile.  There    are    funds    available    from  various 

government    agencies,   such   as    the   National   Institutes    of 
Health,   the   Vocational   Rehabilitation    Administration,    and 
the    Department    of  Labor,    for  investigations   Into  problems 
of   this    kind. 


Washington,    D.    C.      2  0210 


56 


QUESTION   DIRECTED  TO  EUGEME    P.    MURPHY*:      Would   you 
discuss    recent   developments   in  non-visual   reading   devices? 

DR.    MURPHY:      This   is    a   case    of  aid  to   those    much   more 
seriously  handicapoed  than   many   included   in   the    category   of 
"visually   limited".      There    are   many  oeoDle   who,   even   with 
the   best   visual   aids,    are   not   able    to   read.      Then   what    can 
be   used? 

The   Prosthetic    and   Sensory   Aids   Service   has   been 
conducting  or  supporting  experiments    for  years   with 
electronic   devices  which   scan   the   material    (with   orooer 
illumination   and  magnification)    and  then,   project   it    on 
an   array   of  photocells   that  might   do   a  various   number  of 
things    to  yield  either  audible    or  tactile    output.      Our 
oroblem  is   to   offer   simolicity   of  one    tyoe    combined  with 
comolexity   of  another  against    other  choices    of  combinations 
so  as   to   allow   clinicians   to    find  the   best   balance   point 
for  each    individual   or  set   of  circumstances. 

One   might  have    simole    devices    that   put   out    various   tone 
oatterns,    or   other   choices   uo   to   conrolex   devices   oronouncing 
words,    or  at    least   names    of  individual   letters,    or  any    of  a 
series    of  intermediate    stages.      Instead  of  audible    outouts, 
one   might   have    something  as    simole   as    a  device   that   tickled 
the    fingers    as   a  tactile    output,    uo   to  a   machine    that   would 
oroduce,    say,    something   like    Grade    One    or»   Grade   Two  braille 
if   one   could   recognize   the   actual    letters,    as    inout   to   a 
translator. 

Furthermore ,    one    can   have    something   that   mechanically 
is    simole    at    this   end,    and   likewise    cheao,    uo   to   a   machine 
that   is   quite    complex  mechanically  but   Dsychologically   simole 
in   terms   of   output   to  the   user.      Unfortunately,   we   are  not 
able    to  have    something  both    simole    mechanically   and   simole 
osychologically.      To  make    something  simole   psychologically, 
that    talks    actual   words,   tends    to   require    a   complex  mechanism. 
Also,   we   can   have    various    combinations    falling   in   between 
these   extremes. 

The   very   simplest   device   would  be   something  using  a   single 
photocell   with   outout,   either  a   single   tone   or   a  single   tick- 
ling of   the    fingertio,   wherever  the   cell    "sees"    black    (or 
conversely,    it    could  tickle    when   it    "sees"    white,   and  stoo 
when   it    "saw"    black,    whichever  way   you  want    it).      There   have 
been    such   devices   which   are   orobes.      The   Hear-a-Lite   was    one 
examole,   produced  with   the   aid   of  the    Lions   Club   in   Batavia, 

*Ph,b.  ,    Chief,    Research   and   Development    Division,    Prosthetic 
and   Sensorv   Aids    Service,    Department    of   Medicine   and   Surgery, 
Veterans   Administration. 


57 


Mew  York,    some   years   ago.      The   American   foundation    for   the 
Blind  has    a   device    called   the    Audivis.      The    Germans   also   had 
this    sort    of   device.      Recently,    some   oeoole    interested  in 
training   blind    individuals   to   be    comouter  orogrammers    developed 
a   simple   Drobe    to   sense   the    illuminated   lights    on   the    control 
Danel   of  the    computer.      It's    imoortaot    for   the    blind   orogrammer 
to  keep    informed   as   to   the    signal    lights   which   are    disnlayed. 
(Comouter  programming  turned   out   to   be   quite    a    e;ood   .iob    for 
intelligent   blind  peoole.)      Devices   with    a   single   ohotocell 
and   single    output   exist,    develooed   time    after  time,    but   none 
has    really   become   popular  because,    I   think,    oeoole   exoect    too 
much   of  a   relatively    simole    device. 

The  next   type    of   device    would  be   a   direct    translator 
of  the   shaoe    of   the    blackened   character  into  either  tone   oatterns 
or  tactile    signals    related   to   soeed   o^   scanning.      One    such   tyoe 
is   the    oDtoohone,    invented   in  England   ,1ust   before   World  War  I, 
with    a  oroduction-engineered   version    in    1920.      An   English   lady, 
Miss    Mary  Jameson,   has   been   using  the    ootoohone    since   World 
War  I,    and  has  benefited   a   good   deal    from  it.      Relatively 
few  oeoole   have  ever  taken   the   trouble   to   learn   this    code    in 
which   a  hyohen   would  be   a   sustained   oure    tone    of  an   inter- 
mediate   frequency.      A    caoital   L  would  be    a   chord,    followed 
by   a  sustained  tone,    and   a   slash   mark   /,    a   succession    of   rising 
tones,    very  much   as   if  one    drew   the    shaoes    of   letters   as    musical 
tones    and  Dlayed   them  raoidly    on    an   electric    organ.      The   soeed 
of   deciphering  this    code    is    slow,    but    at    least    there    are    such 
devices. 

Battelle    Memorial    Institute    in   this    country,    under  soonsor- 
shio    of  the   Veterans   Administration,    develooed   an    imoroved 
transistorized   version   of  the    ootoohone,    and   finally   orocured 
ten   copies   of  their   fourth   model,    which  had  a   reasonable   state 
of   reliability.      It    was    built   into  a   lady's   train  case,    a   sub- 
stantial  oiece    of   luggage    but    more   oortable    than   many  t  aoe 
recorders.      Battelle    devoted   much    or   its   oroject   to   development 
of  a   training  orogram  of  200    lessons,    and   we   have   trained   a 
handful    of  Deoole   with   this    device.      They   tyoically   reach    in 
the    order   of   ten    or   fourteen   words    a  minute    in   the   eighth    grade, 
or  adult    level;    from  there    a    steady   user  can    continue    to  use    it 
reasonably   well   with   slowly    increasing  soeed  and   versatility. 
Soecialized   reading  materials    in    any    field    (like   the    Greek 
words    used   in   oohthalmology   and   optometry)    are   oerfectly   under- 
standable   in   that    field,    even   though   they   may   seem  strange    to 
outsiders. 

There    is    an    imoroved  version    of  this    direct-translation 
orinciole    called   a  Visotoner,   which   Mauch    Laboratories   of 
Dayton,    Ohio  have   built    for  the   Veterans   Administration.      The 
Visotoner  is   still   smaller   and   more   oortable    and    fits   in    a 
little   camera   case    on    a   strao    over  the   user's   neck,    or  in   an 
attache    case.      Ultimately,    it   will   be    built   to   fit    in   a   man's 
oocket . 


58 


The    analogue    on    the   tactile    side    is    the    Mauch   Visotactor, 
which    tickles    the    finger>tios    as    it  orobes    along-   over  the    line 
of  orints.      Where    the   ohotocell   "sees"   black,    there    is    a   little 
tickling   over-   the    aoorooriate   side    of  a   fin";ertio   so   the    subject 
has    the    sensation    of   drawing  his    finders   over  a    large    sandoaoer 
reolica  and    learns    again   to   re c o r?r\ i ze    the    individual    letters    at 
the    seven-  to   ten-words-ner  minute    level.      The    Battelle    train- 
ing oroprram  can   be    used  with   either  the   Visotoner  or  the 
Visotactor. 

You   can    say,    "This    is    hooeless;    all  of  us   sighted  oeople 
know   that   nobody   would  want    to   read   that   slowly."      Yet    some 
few  oeode    think   this    is    some    value    to  them,    if  they    are 
blind  oeoole    and   are   not    able    to   read   otherwise.      \t  Hines 
Veterans   Administration   Hosoital    a  blind   braille   instructor 
is   quite    an   enthusiast   about   the    ootoohone   and  Visotoner, 
and  has    gone    through    the   training;  pronrrqm.      Now  he   writes 
lengthy   and   glowin"-   reoorts    about   his   exoeriences. 

We    are    in   the   orocess    of  buying  a    few   more    conies    of  Viso- 
toners    and  Visotactors,    and  v/e   hooe    to  have    some    individuals 
trained  with    them.      Thev   are   still  highly    controversial;    some 
oeoole    assure    you  that   these    devices    are   hooeless   and  that 
nobody   would  be    interested  in    reading-  at    onlv   ten    or   fifteen 
words    a  minute.      This   soeed   certainlv   is   not   very    much.      Yet 
the    remark   was   made   earlier  today    about   the    difficulties    of 
reading;  with   hip-h-oowered   lenses,   where   partially   sighted 
oeoole    can    see    only   a   few  letters    at   a  time    and  have    difficulty 
in   stringing;   them  together  to  make    a  word.      Part    of  the   oroblem 
is    that   such   a   system  is    slow   and  annoying;  if  you   are    trying;  to 
read   Ions;   connected  passages.      Mevertheless ,    we   have    a   subject 
who   is    trying;  to   read  a   book   with   her  Visotactor,    though   we 
would  not    really    advocate   the   machine    for"  book    reading;.      We 
think   it   is    good   for  the   isolated,   brief  job,    as    somebody 
said   this   morning   in   rep;ard   to  magnifiers    for  recognizing 
numbers    on   the    thermostat.      Direct   translators    may   also  helo 
in    finding  which    side    of  the    sheet   has   the   orinted   letterhead 
before    starting   to  touch-tyoe    a    letter.      Thay   have   been  useful 
in   checking  personal  mail,   bank  account,    return    statement 
from  the   bank,    and   checking;   over  a   Christmas    card   list.      Some- 
times   it's   inconvenient    to   find   a   sighted   colleague    to   read 
for  you,    or  a  blind  oerson   doesn't   want   to    ask   a    landlady  to 
come    to   check   the    letter   from   social   security   and   lose    all   the 
orivacy. 

At    the    othef*  extreme,    one    could  have    some    sort   of  recognizing 
machine,   which    given   the   signals    from  the   oresence    of  black,    would 
actually    recognize    the   way   a   vertical   line   means    a    lower-case    1, 
or  the    vertical,   then   a  horizontal   line,    and   finally   a  smaller 
vertical    line    means    a   lower-case   h,    and  so  on.      Then   such 
machines    can   "read".      So    far  these   are   bis,   exoensive   machines. 


59 


(Just  as   we   left   the   hotel  after  the  excellent   lunch   today, 
I  noticed  the    sign   on   the   next   building,    "Farrington"  ,    a 
pioneer  and   one    of  the   several  companies   which  now  build  this 
kind  of  machine,    for  recognizing  credit    card  vouchers   or  for 
a  number  of   other  business   purposes. )      They    are   typically 
from  $50,000  to  half   a  million    dollars,    depending  on    facilities 
desired.      If   you  are    satisfied   just    to   read   ten   digits   of  a 
single   prescribed   font,    then   you   may    get   a   machine    for   only 
$50,000.      If  you  want   to   read  multiole    fonts   and  bound  books, 
such   a  machine    runs    up   the   order  of   $400,000   and   $500,000, 
and  some    of  them  are   not   very   good  or  reliable   as   yet. 

Mow,    our  problem  in   working   for  the   blind   is    to  try   to 
find  a  machine   that   will   recognize   any   of  a   variety   of  type 
fonts,    in   correspondence,    magazines,    or  books,    and  will  be 
in   the   price    range    of  an   automobile.      That   is    what   Mr. 
Mauch   is    working  on,    using  a  Visotactor  to  carry   the   input 
photocells.      So   far,   he    is   strictly   in   the    laboratory   stage, 
but  he  has   some   hope   that   in  a   few  years   to  come,   he   will 
have   a  practical,    moderately  portable    device    within   the 
price    range    of   an   automobile,   and  a  weight   in  the    order  of 
a   35-pound  portable   tape    recorder  or  electric   typewriter. 

If  you  once   recognize   the    letters,   there   are   several  kinds 
of   output.      One   would  be    "spelled-speech" ,    developed  by  Dr. 
Metfessel,    in  Los  Angeles.      Instead   of  getting  staccato, 
THE,    as   in  an   ordinary   children's   spelling  bee,   the    letters 
will  blend  together  in  any   variety   or  random  order  that   may 
arise.      So,    the   word  T  H  E   is   pronounced   like   "TAYCHEE",   a 
coalesced  word-like    group,   which   after  about   ten  hours   of 
training   (instead  of  200   hours    for  the   optophone   or  Visotoner) 
can   be   recognized  quite    readily.      Instead  of  10,    15,   maybe    30 
words   a  minute   with  the    simpler  devices,    Mauch  expects   to 
get   about    80  to   90   words    a  minute   with  the   Metfessel   "spelled- 
speech".      This   speech   is   equivalent    to   slow  public   speaking, 
but    spelled  out.      We  had  some    test   passages   at    these   speeds. 
When   you   first  hear  them,   they   seem  hopeless,    but  after  awhile 
to  your  surprise,    you  find  yourself  "latching  on"   and  trying 
to   respond  to  questions    asked   in    "spelled-speech."      It 
goes   along  at  quite    a   steady   speed,    and  you  begin   to   recognize 
it   without    conscious   translation. 

The   next   step   beyond  "spelled-speech"   would  be    spoken 
words.      There   are    several  possibilities.      The   Haskins 
Laboratories,   which   were    the   central   laboratories    for  the 
old   Committee    on   Sensory   Devices    of  the   National   Research 
Council   at  the   end  of  World  War  II    (a  program  which  VA  was 
partially  involved  in  sponsoring)   had  continued  to   study   the 
nature    of  speech.      By  now   Haskins   Laboratories    are   world- 
famous   in  the   basic   area  of  speech   studies. 


60 


They  have    felt    that   the    trouble   with   the    outDuts   of 
ootoohones   and  similar  direct-translating  machines    is    that 
they   sound   like  pipe   organs   and  other  devices,   but  they   are 
not   speech-like.      Thus,   Haskins   Laboratories   have    decided 
that   the   only   good  high-oerformance   soeech   machine   would  oro- 
duce    some    sort    of  pronounced  words,   even   though   it   would   take 
a   complicated  machine,    so   bie;  and   so   exDensive    that    it    would 
have    to  be    in   a   central   library.      They  have   built   an   interim 
word-reading  machine   which,    starting  with   recognized   letters, 
looks    uo    the    soelline;  of   the   material    letter  by    letter,    in 
digital    form.      Then    it    finds    on   a  Darallel   track    the 
pronunciation    of  that   word   if  it's    one    of  the    7,000  words 
in   the    recorded   dictionary,    and   then   Dronounces    the   word 
out    again   on   the    auxiliary   tape,    looks    up   the  next   word,    and 
so  on.      The    resulting  passage   is    a  nice    flowing   soeech   with 
rather  odd  inflection,   but   it   is    absolutely   understandable 
with  no    training.      Another  possibility  would  be    the    synthesis 
of   soeech   by    rule.      Both  of  those   turned   out   to  be   quite 
exoensive   ways    of   doinc  the   necessary    job   of  producing  con- 
tinuous  speech.      Haskins   Laboratories   now  think   that   they 
can    find  hybrid   or  intermediate   ways    of  synthesizing  reasonably 
good  soeech,    in   word   groups,   without    completely   storing  the 
material   in   a   massive    dictionary  yet    without    completely 
synthesizing   it. 

Also,    if  you   could  recognize    the    letters,   you   could  trans- 
late   them  immediately   into  Grade   One   braille,    which   is    a   letter- 
for-letter  transoosition   cipher.      This  transfer  is  not   really 
as   simole   as    it   seems.      There    are    some    cases   where   you  need 
two  braille    cells    to   stand   for   one    simple    letter:      for  ex- 
ample,  capital  sign,   and  the    letter,    indicate   the   beginning 
of  the  word,   but   the   capital   sign   doesn't   always    corresoond 
to   shifting  to   upoer  case    on   a   tyoewriter   or  Teletyoesetter 
in  printing.      If  you  want   all  uDoer  case,    you  use   two   capital 
signs   in   a   row,    then  emboss   the    same   cells    as    for   lower  case 
letters.      If  you  are   willing  to   have    a  more   elaborate   comouter, 
which   IBM  has    developed   for  other  purooses,   you   can   go   from 
the    spelling   through   the    computer   to   Grade    Two  braille,   which 
is    a  contracted  shorthand  type. 

Incidentally,    I    should  mention   that    in   the    translation 
area    for  tactile    devices    there    is    also   a  big  and  elaborate 
machine   which   is   orobably    good   for  things    like   wiring   diagrams 
and  so   on,   embossed   as    large    replicas    on   aluminum   foil,   but 
that   is    almost   in   the   neighborhood  of  machine   comolexity. 

There    is   an   area   in  between   direct    translation    and  comolex 
recognition   which   we   have    called   the   intermediate.      We    some- 
times   dream  that   maybe   we   will   think   of  something  that    is    only 
a   little   more    comolex   than   the   simole   mechanical   devices    and 


61 


almost  as    good  as   the   word-oronouncing  device.      Dr.    Nye    from 
California   Institute    of   Technology   and   a  number  of  other 
oeople    like    to   dream   of   this.      They  think  there    ought   to  be 
an   audible    "foreign"    soeech-like    outout   which,    though    it 
would  not   be    a  true    soeech,   would  not    require    recognizing 
the   material.      So   far,   this    concent    is   highly    soeculative. 
Mauch   started  in  this    intermediate    area,    as    a  matter  of   fact, 
yet    found  himself   forced  toward   the   more    complex   recognition 
machine    to   make    a    ecood  machine    for  reasonably  high    soeed. 
Yet,    as   a  by-oroduct,   he   had  a   simole    direct-translating 
orobe   which  he   had  used  to   carry   the   photocells    sending 
signals   to   the   matrix  which    did  the    recognizing.      He    thus 
had  the   Visotactor  as    a   detachable   by-oroduct   carrying  the 
photocells,   the    light   source,    and   so   on,    and  the   Colineator 
for  tracking  along  the    line   of  tyoing. 

These   Visotoners,   Visotactors,    and  Colineator  tracking 
devices    could  be    available    in    a  couple    of  years.      We    already 
have    a   few  Battelle    optoohone    devices   which  now   conceivably  . 
could  be    used  as   training  aids    for  those    few  oeople    that    are 
willing  to    go  through   the   extensive   training  program,      I 
believe   there    are_  such  oeoole.      Some    years    in  the    future,    we 
will  have   more   elaborate    devices    requiring   less   training, 
allowing  higher  soeeds,   but    costing  more.      We  need   to  keen 
uo  enthusiasm  about   the    field  and  to  keen   dedicated  oeoole 
busy,   thinking   and   makinp;  both   ma1  or   goals    and  useful  by- 
oroducts.      They   eventually  will    fill   in   the   whole    SDectrum 
of  reading  aids    for  the   blind  and   the    deaf-blind. 


252   Seventh    Avenue 

Mew   York,    New  York      10001 


62 


PANEL    3 

"Servinp-  the   Social   and  Economic   Meeds 
of   our  Visually-Limited  Peoole" 

Evening  Session,    March   24,    1966 

Panel  Chairman   -  EDWIN   B.    MEHR,   0.    D.  , 
Chairman,    Committee    on   Aid  to  the   Partially-Sighted, 
California   Ootometric    Association 


****** 


PAPERS    PRESENTED    BY 

Charles    Gallozzi,    Assistant   Chief   and  Mary    Tack 

Wintle,   Assistant   Selection   and 
Publications   Officer,    Reference 
Deoartment,    Division    for  the 
Blind,  Library   of  Congress. 


Terence    Carroll, 


Director,   National   Institutes   on 
Rehabilitation   and   Health   Services. 


Sarah   H.    Butts 


Medical   Services    Soecialist,   Bureau 
of  Family   Services,    Medical  Services 
Division,    U.S.    Deoartment    of  Health, 
Education   and  Welfare. 


RESOURCE    PANELISTS 


William  B.    Parsons,    Assistant   Chief   for  Program 

Develooment,   Neurological   and 
Sensory   Disease   Service    Program, 
Division   of  Chronic   Diseases. 


Bureau   of  State 
Health   Service,   U.S. 
of  Health,   Education 


Services,   Public 
Deoartment 
and  Welfare. 


Keith   Jennison 


President,   Keith 


Jennison   Books 


Eranklin  Watts 
Incorporated. 


Division,    Grolier, 


J.    Arthur  Johnson , Executive    Director,    Columbia   Light- 
house   for   the    Blind. 


63 


LOOKING  AHEAD 

Charles  Gallozzi*  and 
Mary  Jack  Wintle** 


Part  I  -  Mr.  Gallozzi 


One  thing  I  have  learned  in  the  more  than  fifty  years 
I  have  been  here  on  earth  is  that  we  might  as  well  accept 
the  fact  that  a  woman  is  going  to  have  the  last  word  anyway, 
so  I  have  asked  Miss  Wintle  to  wind  up  this  presentation. 
Another  thing  you  need  to  remember  is  that  by  experience, 
by  training,  and  by  profession,  I  am  a  librarian. 

We  have  a  great  many  peoDle  come  to  us  because  they 
can't  read,  but  they  have  to  be  "legally"  blind  and  meet 
the  requirements.   Unless  they  have  visual  acuity  of  20/200 
or  less,  corrected,  they  are  not  eligible  for  our  service. 
Their  optometrists  and  ophthalmologists  may  say  that  if 
they  don't  meet  this — they  have  more  sight  than  this;  and 
by  generally  accepted  standards  if  they  have  more  sight  than 
this — they  should  be  able  to  read.   But  the  reading  that  I 
am  speaking  of  is  not  the  seeing  of  a  single  letter  on  a 
chart  or  the  reading  of  a  phrase.   As  a  librarian,  I  am 
speaking  of  reading  not  only  words  and  phrases,  but  sentences, 
paragraphs,  newspapers,  magazines  and  books,  and  reading  them 
with  enough  ease  and  comfort  to  en.joy  them.   So  when  I  sneak 
of  reading,  keep  in  mind  its  rather  broad  definitions. 

It  is  noteworthy  that  the  American  Optometric  Association 
is  concerning  itself  with  social  and  economic  services  available 
to  visually  limited  people.   In  carrying  out  our  library  orogram 
for  legally  blind  persons,  we  at  the  Division  for  the  Blind  of 
the  Library  of  Congress  have,  for  a  number  of  years,  been  work- 
ing with  professional  organizations  and  urging  them  to  plan  and 
act  beyond  their  prime  spheres  of  activity,  and  we  have  received 
some  rewarding  cooperation.   Publishers  who  produce  books  with 
print  designed  for  normal  sight  are  gladly  making  it  possible 
for  their  books  to  be  recorded,  or  embossed  in  braille,  without 


*Assistant  Chief,  Division  for  the  Blind,  The  Library  of  Congress 

**Assistant  Selection  and  Publication  Officer,  Division  for 
the  Blind,  The  Library  of  Congress 


64 


any   thought    of   royalities    or  other  charges.      Public    librarians 
are    becoming  aware    that   their   skills    and  knowledge    are    just    as 
valuable    when   used   to  help   a  blind  or  visually    limited  oerson, 
as   they   are    to   the    general  public.      In   the   past    few  years, 
educators   have    discovered  new  dimensions   and   greater  potential 
for  their  field  through   techniques    and  media   devised   for 
children   who  are    visually   handicaoped.      And,    of  course,   the 
activities    of  the    American    Ootometric   Association   are   encouraging 
in   demonstrating  its    capability    for  thinking  in   terms    far  beyond 
the   measurement    of  visual   acuity   and  the   prescribing  of   aDpro- 
priate    lenses.      The    social   and  economic    welfare    of  all  people 
has   become    the    concern   of  all   of   us,    and   I    want    to  thank   all 
of   you,    and  particularly   your   officers    and   committees,    for 
showing  leadership   and   initiative.      There   are    a    great   many   other 
professional   associations   which   have   yet    to   follow  your   lead. 

There    are    two    factors   which   will   limit   my   discussion  of 
social   and  economic    services    available    to  persons   with   limited 
vision.      The    first    is   my    lack   of  information   on   services    avail- 
able  to  persons   who   are   not   blind   but   who   are    visually   imoaired. 
The   second   is   the    fact   that   this    group,    numbering  at    least   half 
a   million   people,   has    found   very    few   official   sookesmen,    few 
organizations   to    fight   their  battles   or  present   their  problems. 
Therefore,    I  will  have    little    to   report    in   the    way   of  oresent 
services.      Such    services   exist   primarily   in  the    field   of 
education   of   children,    and,    In   a   rather   small   way,    in   the 
vocational   rehabilitation   of   adults.      Looking  ahead,   the   picture 
may   become    brighter,    but    only   if   the   need   for  social   and  economic 
services    is   oointed   up.      At   present   this    is   being  done    in   the 
area   of   reading,    and  as    an   example,    I  would   like    to    read  you  a 
letter  which   reached   me    last    December. 

"Los   Angeles   City   Schools 
Bertrand  Avenue    School 
7201   Bertrand   Avenue 
Reseda,    California 

Dear  Sir: 

I   am  writing  you   regarding   the    distributing  of   talking 
book   records.      I    realize   the    logic   of  distributing  them  to 
legally  blind  people.      However,    as    a  teacher   of  partially   see- 
ing children,    I   wish  to  question  this    system  for  the    following 
reasons: 

As   you  are   probably   aware,    there   is    a  multitude   of   read- 
ing  material   available    to  the   normally   seeing,    and  there   is   a 
substantial  amount    of  braille    and  talking  book  publications    for 
the    blind.      However,    only    a  limited  number   of  textbooks    and 
almost   no   spare   time    reading  books   are   printed   in   large   print 
for  the  partially   seeing. 


65 


Although   some    legally   blind  peoDle   have    distance    visual 
acuity  less   than   20/200,    their  near  vision  may   be    sufficient 
so   they   can   read  small  print.      On   the   other  hand,   there   are 
people   who   are   not    legally  blind   (those   whose   distance   visual 
acuity   is    between   20/70   and  20/200)    but   who  have    great   diffi- 
culty  in  reading. 

I   am  writing  about    one    student   in  particular  who  has  been 
denied   the   use    of  talking  books   since   his    vision   is   20/100. 
This    child   is    a  6th   grader,    a   very   bright   boy  who   is   capable    of 
reading   and  comprehending   at   an   8th    grade    level.      He   has    a  keen 
appreciation   of   good  books   and   loves   to  learn   from   them.      How- 
ever,  near  vision  activities   present    a  problem  due    to   his   con- 
stant  nystagmus   and   the    resulting   difficulties    in   focusing  his 
eyes   on  the   print.      He    does  not   qualify   as    legally  blind;    he   can 
even   "read"    small  print   materials.      Yet,    I    cannot    consider  this 
as   reading  in  the   true   sense    of   the   word.      A   more    accurate 
description   is   that   he    struggles   through   small   material — and 
to  a   lesser  degree,    large   print    material. 

This    is   the   kind   of  vision   problem   that    is   too  often 
overlooked,    as   the   child  can,    with   a   great   deal   of   time    and 
effort,    "manage".      He   was   in   a  regular  class   without    large  print 
materials   until  last   year.      When  he   was   given  a   small   print 
reading  test    one   year  ago,   he    scored  at   a  beginning  fourth   grade 
level — he   only  had  time    to    do   a  portion    of   the   test.      This   year, 
given   a   similar  achievement   test,    in   large   type,    but    with   the 
same    time    limits,    he   scored  at   the    seventh   grade    level.      With 
50   Dercent   additional   time,   he    scored  at   almost    9th   grade    level, 
but    still   did  not   have    sufficient   time    to   complete    the   test. 

Reading  is    so   slow,   painstaking,    and  emotionally  exhausting, 
especially    in    small  print,    that   regardless   of  the    interest    this 
boy  has    in  a  particular  book,    it    is   quickly    replaced  with 
frustration   and  negative    feelings. 

Of  my   twelve    students,    five   are    legally   blind,    while    seven 
fall   in  the    range    of   the  partially   seeing.      All    read   large   print; 
most   can   read  or   struggle   through   small  print   with  varying 
degrees    of  difficulty.      Of  my    five    legally   blind   students,    I 
feel   that    two   have   no  need   for  talking  books   because    of  their 
usable  near  vision.      Of  the    seven   children   who  are    not   legally 
blind,    however,    five   have    sufficient   near  vision   problems   to 
make    reading  an   unpleasant    chore    and   to  make    the   possibility   of 
their  using  talking  books    a  real   blessing  and   invaluable    aid. 

I    am  wondering  if   there    is    a  possibility   of  making  these 
services    available   to  peoole    such   as    I   have   described. 


66 


I  hope   you  will   give    this   matter  your   serious    consideration. 
I   certainly   appreciate   your  wonderful  work,    and  as   a  former 
teacher  of  blind  children,    I    am  aware   of  the   joy  made   possible 
through   talking  books.      I   am  hoping  that   we   can   share    these 
excellent   talking  books   with    children   who,    although  not   legally 
blind,    have    severe    vision   problems. 

Sincerely, 

Teacher 

Bert  rand  Avenue 

Elementary   School" 

If   a  number   of  pleas,   equally  eloquent,    are   made    for   other 
services,    I   believe    that   they  will  bring  about   results. 

I   have   already   mentioned  educational   services.      Last    year 
Congress   passed  the    largest    single    aid-to-education  bill  ever 
proposed,   the   Elementary   and   Secondary   Education   Act.      It   is 
projected   that   more   than  a   billion   dollars   will   be    distributed 
to   local    school   districts   through   state   education   agencies    dur- 
ing this   year.      Children   with   visual   impairments   will  benefit 
along  with  all   others,   and  particularly   because    of  the   emphasis 
on      audio-visual   materials.      The   Elementary    and   Secondary   Educa- 
tion  Act  also   specifies   that   the  needs   of  children  and  teachers 
in  private   as  well   as   public  schools   must   be   considered. 
Through  this    act,    and  several   others,    grants   are   available    for 
the    training  of  teachers,    teacher  aides,    consultants,    and   other 
personnel    in  the    areas    of  special  education   which   is    so 
often  necessary    for  children   with   visual   impairments. 

Title   VII    of  the    National   Defense   Education   Act   now 
provides    five   million   dollars   a  year  solely    for  experimentation 
and   development    of  new  educational   media,    and  new  methods   of 
using  existing  media,    such    as   magnetic   tapes,    video   tapes,   and 
motion   pictures.      Much    can  be    done   here    for  children  with 
limited   vision   if  imaginative   plans   are   proposed.      The    Division 
of  Handicapped   Children  and   Youth    of  the    Office    of  Education 
is    specifically    concerned   with   improving   their  education    in 
various   learning  situations.      Research   and   develoDment    grants 
are    administered  by  that   Division   under  the   provisions   of  Public 
Law   88-164.      For  purposes    of  the    law,   the   term  handicapped 
includes    sight   deficiency. 

As    far  as    federal   funds    are    concerned,    the   emphasis    is 
justifiably  on   children.      But   the   parents   of  visually   impaired 
children,    and   visually   impaired  adults,   will  also    require   pro- 
fessional  assistance    if  they   are    to  develop   satisfactory    relation- 
ships  with   their  children   and  with   society.      Here   the   American 
Optometric   Association   can  play   an  even  more   vital  part   than 
it    is   now  doing.      Sessions   such   as   this    one    are    valuable    in 
uncovering  resources   in  health,    education,    and  welfare   to   assist 
in  meeting  individual  needs.      But    such   resources   must   be   brought 


67 


to  the   attention   of  those   who  need  them.      Some   partially   seeing 
persons   may   go  unrecognized  unless    they   are   not    only   identified 
but   properly   referred.      Supervisors   and  consultants   in  charge 
of   state   and   local  programs   report    that   they   find  one    visually 
handicapped  child   for  every   1,000   to  1,500   of  the    school  age 
population.      Blind  children   tend  to   be    reported  at   about   the 
rate    of   one    for  every   3,000   to   4,000.      A    school   official   in   a 
large    system  may  expect   to    find  20   to   30   mentally   retarded 
children,    and  perhaps   as   many   as   10   deaf  and  hard   of  hearing 
children   in  his    schools    for  each   visually   handicapped  child  in 
need   of   special   services.      To   what   extent    are   these    figures 
valid? 

Visual   impairment   directly   affects   reading.      Since    reading 
and  making  it   as   easy   as   possible    for  all  people   to  read  are 
among  the   prime    interests   of   librarians,    I    can  not    get   into 
an   area   in  which   I    can   claim  to  be   knowledgeable.      According 
to  a   study   completed   last   year  by   the   American   Library  Asso- 
ciation,   and   I   quote,    "anyone    who   wants   to  publish   material 
for  readers   with   limited  vision,   and  do  it   without    spending 
a   great   deal   of  money,   should   find  the   material  he   wants 
already   in  print  and  have    it   enlarged  photographically". 
It   had  previously  been  established   that   it   is   not   necessary   to 
exceed   18-point   type    to  provide    the    greatest   benefit    for  visually 
handicapped   readers.      Actually,   the    study   confirmed  what   was 
already   known   from  experience   in  the  production    of  testbooks    in 
large   type.      Its    greatest   value    lay  in  the  encouragement    it 
could  give   to  publishers   with   the  knowledge   that   such   a  process 
would  be  highly   satisfactory. 

Even  before   that   study   was   completed  the   Keith   Jennison 
books   appeared  in  attractive    format,   convenient    size,    and 
18-point   type   at    a  price   comparable   to  standard  editions.      They 
were   the   first   popular  books   of   general  adult   interest   to  be 
issued  in   large   type   in  a   sizeable   edition.      Other  publishers 
have   already   indicated  that   they  will   follow  suit,    and  the 
future    for  the    reader   of   large   type    is   now   far  brighter  than   it 
was   just    two   or  three   years   ago. 

For  more    than    30   years   we  have   been  providing  recorded 
books    for  blind  persons   as  substitutes   for  the  printed  books 
they   could  not    see   to   read.      Among  the   blind  eligible    for  this 
service    were   many  who   had   sufficient    residual   vision   that   they 
could   read  print,    but    only  with   great    difficulty,    as    indicated 
by  the    letter,    which   I   quoted  earlier.      Such    individuals    read 
print   when   they   must,   but    would  not   think   of   reading  as  a 
form  of   relaxation,    or  enjoyment,    or  an   adventure    to  be 
embarked  upon   with  pleasant   anticipation.      Those   who   are   eligible 
find  the    relaxation,    enjoyment,    and  anticipation   in  talking  books, 
which   In  practically  every   case   provide    supplementary    and 
recreational   reading  rather  than    so-called   required   reading.      No 


68 


one   could  think   of  denying  them  that  privilege,    just   because 
they   can   read  with   difficulty.      Yet,   there   are   thousands 
of  persons   who  are    in  exactly   the   same    situation  except   that 
you,    as   optometrists,   and   the    ophthalmologists,    on  examining 
them,    find  that   they  are   not    legally   blind,   and  we,    therefore, 
cannot   provide    them  with  talkingbook  service.      Just   as   I   had 
to   say   "no"   to   our  teacher   correspondent,    we  have   been    saying 
"no"   to  thousands   whom  we    felt   to   be    in   genuine   need   of   our 
services.      But   every   time    we    said   "no"   we   became   more    determined 
that    something  should  be   done    about    it. 

I   have   here    copies   of   H   bills   which   were    introduced  into 
Congress    just    last   week.      I   will   give    you  time   to   take    out    your 
pencils   and   make    some    notes,    for  it   is   my  hope   that   you  will 
want   to   support   them.      S.    3076*   was    introduced   on   March    14,    1966 
by   Senator  Hill,    for  himself   and  52    other  Senators.      Its  pur- 
pose   is    to  extend  and  amend  the    Library   Services    and  Construction 
Act.      Part    B  of  Title    IV  authorizes   to  be   appropriated  25   million 
dollars,    over  a  period   of  5   years,    specifically,   and   I   quote, 
"for  establishing  and   improving  library   service    to  the  physically 
handicapped,    including  the   blind  and   the    visually  handicapped. 
For  the   purpose    of  this   part   the   term   'library   services   to  the 
physically  handicapped1    means   the   providing  of   library   service, 
through  public   or  other  non-profit    libraries,   agencies,    or 
organizations.    .    ."      To   the   best    of  my  knowledge   this   is   the 
first   time   that    visually   impaired  persons  who   are   not    legally 
blind  are   spelled  out   as  being  entitled  to    library   service 
through  federal   support.      This    bill  was   referred  to  the   Senate 
Committee    on  Labor  and  Public  Welfare.      On  March   16,    Congress- 
man  Fogarty   introduced  a   similar  bill,   H.R.    13697,    in   which   Part 
C   of  Title    IV  is    identical  with  the    one    I   have   just    described. 
Mr.    Fogarty' s   bill   was    referred   to   the   House   Committee    on 
Education   and  Labor.      On   March   17,    Senator  Jordon    introduced 
S.    3093**.      This   bill   would  amend  Title   2    of  the    U.S.    Code, 
section   135,    which   is   the   basic    law  establishing  the   books    for  the 
blind  program  in  the    Library   of   Congress.      Whereas   our  services   are 
now   restricted   solely  to  persons   who   are    legally  blind,    S.    3093 
would  make   them  available   to  blind  and  to   other  physically 
handicapped  readers  who   are   unable   to   read  normal  printed  material 
as   a  result   of  physical   limitations.      Senator  Jordan's    bill   was 
referred  to   the    Committee    on   Rules    and  Administration.      On  the 
very   same   day,   Congressman   Burleson   introduced  H.R.    13783  which 
is   Identical  with  Senator  Jordan's   S.    3093,    and  it   was   referred 
to  the    Committee    on  House   Administration.      So,    within   a  period 
of   four  days,    just   one   week   ago,    Congress  has   been   asked  to  ex- 
tend the   use    of   recordings    and   other  suitable    reading  media   to 
visually   impaired  persons,   both  children  and  adults,   as   a  public 


*These  provisions   were   ultimately   incorporated   into   P.L.    89-511 
which   received  presidential  approval   July    19,    1966, 

**These   provisions   were    ultimately   incorporated   into  P.L.    89-522 
which   received  presidential   approval  July    30,    1966. 

69 


library   activity.      I    feel  confident   that   Congress   will 
respond   favorably,    and  I   hope   that   your  voices  will  be 
among  those   which   will   urge   them   on  and  then   congratulate 
them  for  establishing  a   long-needed   service. 

Part   II   -  Miss  Wintle 

The    local  public   library   is   the   key  to  meeting  the 
reading  needs   of  the   members   of   a  community,   Including  those 
who   are   visually   limited.      For  children  the  public   library  is 
the   place   to   form  reading  habits   that   will  carry   them  through 
life;    for  adults   it    is   the   place    to   continue   those   habits. 

Until   recently,   public   libraries   had   few   resources   to 
draw  upon   for  special   collections  to   serve    visually-limited 
readers.      There   were   children's   books  with   subject,    format,   and 
type   size    for  beginning  readers;    but,   by   and  large,   print   pub- 
lishers had  neglected  the   adults.      A   smattering  of  spoken   re- 
cordings— mainly  poetry,   a   few  plays— were   available,    but   it   is 
doubtful   if  many   librarians   or  readers   thought   of  the   connection 
between  these   and  a  total  reading  program — a  program  that   would 
replace   the   typical   fare   of  the    readers'    regular  type. 

The   current  picture   has   some   bright   spots,   notably  publish- 
ing ventures   such  as  the   Keith  Jennison   Books   which   are   aimed 
directly   at   the   adult   reader.      The    Division   for  the    Blind's 
Reference.  Circular  on   large   type — which  each   of  you   should  have-- 
lists    three    different   publishers  who  now  produce    large-print 
books   primarily   for  adults.      This   number  promises   to  increase 
in  the   near   future ,    and  then   we   may   see   a   bandwagon   reaction 
with   many  publishing  houses   jumping  into  this   market. 

Another  area   for  expansion   in  the   publishing  world  is 
spoken  recordings.      The    talking-book  program   for  the    legally 
blind  has  proven  the    feasibility   and  popularity    of  books   in 
recorded   form.      To   do  chores    around  the   house   and  at   the    same 
time   to   be   able    to   read   via  the   ear  is   an   enticing  thought. 
Why   should   this   privilege   be    limited   only  to   those    legally- 
blind  people   who  are   eligible    for  talking  books?     Also,    not 
everyone    can   use   print,   even  in  an  enlarged  form.      Why   shouldn't 
public   libraries    be   able   to  acquire    recorded  editions   of  books 
as  well  as  print   editions   to  help   in   meeting  reading  needs    for 
all  members    of  the   community. 

What   this    all   means    is    that    some    commercial  publishers 
recognize   a  profitable    and   growing  market    among  the    visually- 
limited.      It   becomes   a  practical  matter   of  dollars    and  cents. 
The    day  will   undoubtedly  arrive   when  books   will  be   produced 
simultaneously   in   regular  type,    large   type   and/or   recorded 
editions — all   by  the    same   publishing  house. 


70 


In   terms   of  social  needs,    the   visually-limited  will  not 
be   ostracized  from  the    reading  public   because   of  their  handicap. 
They  will  be   able   to  continue    reading  experiences   Independently. 
Independence    is    an   important   term.      To  be   able    to   do   for  oneself 
instead  of   depending  on   someone   else    is    to   be   able    to   maintain 
self-esteem.      This    applies   to  reading   as   well  as    other  activities. 

Economically,   the    cost    of  books   in   large   type   or  on 
recordings    should  be    comparable   to   the   cost    of   regular  print 
books.      This   would  not   only   aid  public    libraries   in   building 
collections,   but   would  also  encourage   visually-limited  adults 
to   maintain  home    libraries.      At   present   Drices   vary  widely. 
For  example,    a   subscription   to   Xerox  edition   of   Re_ader's_  Digest 
runs   over  $40.00   a  year;    however,    the   Jennison  books   are   priced 
within  a   dollar  or  so   of  the    original   edition.      With   development 
of   low-cost   reproduction  methods,   the   prices    of  the    special   books 
should  come   within  reach   of  the   average   reader's   pocketbook. 

One    afternoon   last    summer  when   I   was   traveling  in  England, 
I  took  a  busman's    holiday   and   wandered   in   the    small  public 
library   at   Windermere,    located  in  the    lovely  English  Lake 
district.      The    first   thing  that    caught   my  eye   as    I  entered  the 
reading   room  was   a   shelf   of  large-type   books,    the    Ulverscroft 
editions.      The    librarian   on   duty  was  well   informed  on   large- 
type   books   and   their  potential   for  her  community  which   she 
described  as  primarily   a  retirement   area  when  the   summer  tour- 
ists  returned  home.      I  wonder  how  many  public    libraries    in  the 
U.    S.    you  could   visit   and   find   large-type   materials    as  prominently 
displayed?      And  a   librarian   as  well   informed? 

The  AOA-proposed  pilot  project  of  low-vision  reading  centers 
relates  directly  to  this  problem  of  getting  books  and  information 
to  the    local   level   where   they  would  be   most   useful. 

After  all,   public   libraries   are   the   key   to   meeting  reading 
needs   of  a  community — an  entire    community. 


Washington,    D.    C.      20540 


71 


QUESTION   DIRECTED  TO   MR.    GALLOZZI:      How   do   you   get   an 
overworked   librarian   to   take    on   the   extra  workload  of  ob- 
taining materials   for  visually-limited? 


MR.    GALLOZZI:      You  put   more   pressure    on  him,    of  course. 
But   in  all   seriousness,   we  have  been   discussing  this   problem 
intensively  in  the    last    few   days.      The    Library   will  point 
out    to  Congress    that,    if  the   program  is   extended   to   include 
other  handicapped   readers,   we    will  need  additional   funds. 
The    Librarian   of  Congress   is   probably   right   now  still  pre- 
paring his   testimony   because    some    of  us   were    conferring  with 
him  about   it   this    morning.      Adequate    funds   are    one    of   the 
musts  to  any  expansion  of   this   program.      With  funds   you  can 
get   more    staff  and  Mr.    Mumford  will   go  on  record  as   stating 
that,   no  matter  what,    the   existing  program  for  the   blind 
will  not    suffer.      I   am  sure   that   he   would  prefer  to  delay 
the   beginning   of  any  additional   services,    rather  than   to 
cut   back   on   the   existing  services   to   the   blind. 


72 


ECONOMIC    AMD    SOCIAL   SERVICES 
FOR  THE    VISUALLY    LIMITED 


Terence   E.    Carroll* 


I   have    been    asked   to   speak   to   you   regarding  the    view- 
point   of   organized   labor  on   serving  the   economic   and  social 
needs   of   the    visually    limited,    with   some    corollary   remarks 
on   those   needs   which  have    resulted    from  a   work-incurred 
condition.      Before    going  any   further,    I   would  like    to 
insert   one    caveat,    and   that   is    that   I    cannot    soeak    for 
organized   labor;    I    can   only   soeak   about   organized   labor. 
Another  caveat    I   would   like    to   add  is    that   I    really  oossess 
no   special  exoertise    in  the    area   of   the   unique   needs;    social, 
economic,    or  otherwise,    of  the   partially   sighted  and   I    susoect 
that   organized   labor  does   not   either.      However,    I   would   like 
to   think   that    I    am  concerned,    and  I    am  quite   confident   that 
organized   labor  is    concerned,    about   the   economic   and   social 
needs    of  handicapped  people    in   general.      Since    I   happen  to 
feel   that   the   economic   and   social  needs    of  the   oartially 
sighted  are   probably   very    little    different   than   those    of 
other  handicapped  people,    I    think    that   you   should  take    my 
remarks   as   being   general,    and  apply   them  to  the   problems   of 
the   partially   sighted,    as   you    folks   know  those    better  than   I. 

The   economic   and   social  needs   of  workers   cannot   be    separ- 
ated  from  questions   involving  their  health   status.      The 
economic   and   social   well-being   of  a   worker   generally    deoends   on 
his    ability   to  hire   himself   out    in  the    market   place    for   labor. 
Any   condition    of  illness,    or   reduction    in   his   ohysical   or 
mental   caoacity,    tends    to    reduce   his   employability   and  his 
consequent   economic   worth   in   the    .job   market. 

The   crime    requirement    for  every  worker  and  his    family   is 
an   income   sufficient    to  enable    them  to  enjoy   a  modest    standard 
of   living,    and  this    in  turn   depends   upon  his  either  having  a 
job,    or   a   cash   disability   benefit    as    an    income    replacement. 

There    is    little   that    the   trade    union   movement    can    do   to 
create    job    ooportunities    for  any   category    of  handicapoed  persons, 
including   the   partially   sighted.      Unions    do,    however,   play   a 
role   in  preserving  jobs,    that    is,    through   a  number  of   strategies, 
unions   assist   their  members   who   have   become   handicapped,    in    re- 
taining their  employment. 


*Director,   National   Institutes   on   Rehabilitation   and  Health  Services 


73 


1.  Through   the    mechanism  of   collective   bargaining,    unions 
have   provided   the   mass   market    which   has   orovided  the    floor   for 
the    almost   universal   preoayment    of   a  substantial  oortion   of   the 
medical   care    required  by  workers    and  their   families.      Unfortun- 
ately,   most    of  this   oreoayment    for  health   services   has   been 
designed   to   underwrite   the    cost   of   acute   episodic    illness   and 
does   not   provide   payment    for  the    far  more   common   and   far   more 
expensive    chronic    illnesses.      Nevertheless ,    it    can   be   assumed 
that    these   programs    contribute   to  health   maintenance    and,    there- 
fore,   assist   the   worker  in  maintaining  employability. 

2.  Also,    through   the   collective  bargaining  mechanism, 
unions    frequently   have   attained   for  their  members   income    re- 
olacement    benefits,    so  that   during  oeriods    of  orolonged   illness, 
a   substantial  portion   of   the    income    loss    is    replaced  by   some 
form  of   disability  insurance. 

3.  As    an    organized  political   force    in   our  states    and   in 
the   nation,   unions   have    attempted,    and  with   varying  degrees 
of   success,    to   obtain   these    same   kinds   of  benefits    for  the 
population   as   a  whole   through   social    insurance   programs. 
Social    security,   temporary    disability   insurance    and  workmen's 
compensation  are    cases    in  point. 

4.  While   unions    are    concerned  with   individuals    and   their 
rights   and  welfare,    they    do  not    focus   their  efforts   solely    on 
the    individual,    but   are    also   concerned   about   the   institutional 
setting  in  which   men   and   women   work   and   live.      Purveyors    of 
services   to  people--and  particularly   of   services    as   oersonal   as 
those    that   deal  with  health—are   apt   to   deal  with  peoole   as 
isolated  units,    and  are    more    concerned  with   manipulating  the 
patient    than   they   are    with  manipulating  his   environment.      For 
example,    if  a  worker  with   failing  vision   comes   to  an   optometrist 
with   a  complaint   that   he    is   having  difficulty   reading  the  blue- 
orints   on   his   job,    and   in   reading  the   numerical   settings    on   his 
machine,    the    optometrist    is   apt   to    recommend  that   he    wear  an 
optical  aid.      On   the   other  hand,    if  he   complains   to  his    shop 
steward,    the    steward   is    just    as   apt   to   recommend   that   the    company 
increase   the   illumination   on   the   job   and  have    the   numerals   on 
his   machine    increased   in   size. 

The   point    I   am   trying  to   make   here    is    that    unions    are    con- 
cerned about   working  conditions,    and   can   and   do   restructure    the 
job   environment   in  order  to   assist    the   handicaoped  worker  in 
retaining  his   employment. 

5.  Most    unions   have    adopted   the   ooint   of   view   that   a 
worker  has    a   vested   right   to   his   job    and   the    longer  he   works    in 
that   job    the    greater   his    right   to   retain   it.      Operating   from 


74 


that    assumption,    unions   have    developed   seniority   orovisions 
which   protect    older  workers   by   making  certain   that   they   have 
the    right    to   be   emnloyed  at    any   .job   which   they    are    capable    of 
doing   and   to  which    their   job   tenure   entitles   them. 

6.      3ecause    unions    recognise    that    their  members   are 
citizens    first,    they   therefore   have    accepted  a    community 
responsibility    for  the   welfare    of  the   community   as   a   whole. 
The    AFL-CIO  has    created   a  Community   Services    Activities    Depart- 
ment   in   order  to   fulfill   this    resoonsibility.      They   have    trained 
thousands   of  union   counselors    who  participate    in    fund  drives    and 
serve    on   boards    of   voluntary   health   and  welfare    agencies. 

Because    organized   labor   feels    it   has    a   special   responsi- 
bility to    represent    the   working;;  population,    it   has   been 
particularly   concerned  with   .job-incurred   injuries    and   illnesses, 
and  the   treatment   accorded  those    who  have   become    disabled  as    a 
result    of   their  employment.      The    trade   union   movement    is    becoming 
increasingly    convinced  that    the    various   workmen's    compensation 
programs   in   our  country   are    retrogressing  in   the   adequacy   with 
which   they   meet   the   needs    of  injured  workers. 

The   workmen's  compensation    resolution   adopted  by   the   5th 
Constitutional  Convention    of   the    AFL-CIO,    held   in    1963,    detailed 
a    long  list    of  specific    shortcomings    in   workmen's    compensation 
laws   and   administration   and  recommended  21   items    which    should 
be    included   in   every   workmen's    compensation  program. 

Among  the    omissions    cited  were   these: 

"a)      One-half  of   the    states    still   do  not  have   compulsory 
coverage,    and  twenty-nine   exempt  emoloyers   with    less   than   a 
stated  number   of  employees. 

"b)      The    original   intention    of  workmen's    compensation 
legislation   was    to   restore   to   injured  workers   at    least   two- 
thirds   of  the   wage    losses    due    to   industrial   injuries.      There 
has   been    retreat    rather  than   orogress    toward  this    goal.      More 
than   half   the    states  now   have    maximum  benefit    levels    less   than 
50   percent    of   the    state's    average    weekly   wage    for  temporary   total 
disability,    and  only    five   meet    this    standard.      By    contrast,    in    1940 
only  ten    states    had  maximum  benefit    levels    for  temporary  total 
disability — less    than   two-thirds    of   the    state's    average   weekly 
wage — and   only    four   of  these    less   than   60   percent,    and  none    less 
than   50   oercent. 

"c)      Over  a   third   of   the    states    do  not    cover  all   occuoa- 
tional   diseases    and    two   states    still   do  not    cover  any.      In 
addition,    workers    are    frequently   denied   comoensation   under 
existing  occupational   disease    coverage   because   of   restrictive 
time    limits   within   which   they   must    file   a   claim. 


75 


"d)      One-fourth   of  the   states   do  not  provide    full   medical 
benefits   and  a  worker  in  any   one    of  these   states   may  have   to 
bear  a  portion   of   the   medical  cost    for  his   occupational   injury. 

"e)      A    return   to  productive    citizenship   by  every   injured 
worker   for  whom  it   is   conceivably   possible    should  be    the   ultimate 
aim  of  every   workmen's   compensation   law,   but    most    states   still 
do  not    make    rehabilitation  an   integral  part   of   their  workmen's 
compensation   programs. 

"f)      Where   the    injury   is   permanent,    the   benefit    should  not 
be   temporary,   but   half   the    states    limit   benefits   for  the  perman- 
ent   totally   disabled  to   a  period   less   than   the   period   of   dis- 
ability. 

"g)      Not    only   must    the    injured  worker  bear  the   basic 
inadequacies   of  workmen's    comDensation    laws,   but   he    frequently 
has   to  bear  the   additional   burden    of  poor  administration.      Most 
workmen's    compensation   commissions    do  not   check    settlements 
carefully,    and  many   injured  workers,   because   of   lump-sum 
settlements   and   agreements   with   insurance    companies,    do  not 
receive   their  full   rights   under  the    law.      No  worker  should  have 
to  bear  the    double   burden    of  inadequate    legislation   compounded 
by   inadequate    administration." 

At   the    sixth    Constitutional   Convention,    held   in   1965,    the 
APL-CIO   indicated   its   impatience   with   the   continuing   inadequacies 
of  workmen's   compensation    in    rather  strong   language. 

"Too   often,    we   have    found   ourselves   alone    in  the    fight    to 
secure   adequate   protection   for  injured   workers    and  their   families. 
Too   often,   those    who    should  be    in    the    forefront    of   the    fight  to 
secure    improved   workmen's    compensation    legislation   have   avoided 
the    duty   of   leadership   to   accept    the   easy   road   of  inaction.      The 
states   which   have   assumed  the    major    responsibility  have    failed 
in  these    obligations   to   injured   workers.      Under   these   circumstances, 
the    Department    of   Labor  must   take   the    leadership  whether   or  not 
it   has   the    support    of  all   interest    groups.      Its   sole    concern 
should  be   the    interest    of  injured  workers.      It    has   oromulgated 
standards    for  a   good  workmen's    comoensation    law.      A    real  effort 
must   be   made    to   imolement   these    standards.      There    is   no   room   for 
timidity.      This    urgent  need   for  prompt   action   requires   aggressive 
and   forthright    leadership. 

"We   urge    the    Secretary    of   Labor  to   take    a  position    on   the 
major  issues    in  workmen' t    comoensation   and  to   recommend   federal 
legislation  necessary   to   imolement   the    standards   which   have   wide 
acceptance    among   informed  persons   but   little    or  no   recognition 
through   legislative   enactment. 


76 


"The    greatness   of  our  nation   is   not   a   gift.      It  was 
achieved  by  those   of   our  citizens   and  institutions   who   had 
the   courage    to   fight   for  those   causes  essential  to   a   civilized 
society.      Those   who  have   a   special   responsibility   for  the 
occupationally   injured  have   an   obligation  to   lead  the    fight 
in  behalf  of  the    cause.      Therefore,    be    it 

"RESOLVED:      The   Sixth   Constitutional  Convention   of   the 
APL-CIO  requests   the    Department    of  Labor  to   upgrade    its  efforts 
to   improve   workmen's    compensation    laws    and  to   support    vigorously 
federal  minimum  standards   to   implement   those    workmen's    compensa- 
tion  standards   which   the   Department   of  Labor  itself  has    recom- 
mended." 

That   the   attitude    of  organized   labor  toward  providing 
services   to   the   handicapped  is   a  positive   one   Is    demonstrated 
by  the   language   used  in  the   Rehabilitation   Resolution   recently 
adopted  by  the   AFL-CIO: 

"The   number  of  handicapped  persons  who   are   unable    to   func- 
tion  as   self-reliant   members    of  society  is    increasing.      Advances 
in  medical   science   have   prolonged  the    lives   of  many  individuals 
who   in  previous   years   would  have   died  as    a  result   of  injury   or 
disease   and  new  hazards   and   changing  technology   are    contributing 
to  the    increase   in   those   persons   unable    to   function  at    maximum 
potential. 

"Society  must   make    adequate   provision    for  the    care    of   the 
disabled.      Every  effort   must   be   made   not    only  to   care    for  this 
increasing  number   of  disabled  persons   but  to   return   them  to 
productive   activities.      Organized  labor  has  particiDated  actively 
in  the   work   of  the   National  Advisory   Council  on   Vocational 
Rehabilitation,    the    President's   Committee    on  Employment   of   the 
Handicapped  and   similar   state    committees,    and  on  the    community 
level    to   promote    job   opportunities    for  the    disabled.      Organized 
labor  applauds   the  progress   that  has   been  made    in   recent   years 
by  both  public   and  voluntary   rehabilitation   agencies   in   rehabil- 
itating the    disabled,    and  particularly   commends   the   Vocational 
Rehabilitation   Administration  and  its   Commissioner  for  the    leader- 
ship  provided  in   the    rehabilitation    field.      Yet   much  more   must 
be    done.      Therefore   be   it 

"RESOLVED:      that,    the    AFL-CIO   reaffirm   its   position   on 
rehabilitation  adopted  by   the   Fifth   Constitutional  Convention   of 
the   AFL-CIO  and  urges   all  state   and   local   central   bodies   to 
support    legislative   action  matching  maximum  amounts   of  state 
funds   to  available   Federal  appropriations.      Further,   we   urge 
aggressive    implementation   of  the   1965   amendments   to  the   Federal 
Vocational  Rehabilitation  Act   and  the    rehabilitation  amendments 


77 


to  the   Social  Security   Act   to   the   end   that    maximum  state   and 
local  resources   will  be   mobilized    for  comorehensive    rehabilita- 
tion  programs.      Affiliated  bodies    are   urged  actively   to  partici- 
pate  in  programs    to  identify   members    of  union   families    requiring 
rehabilitation   and  to   refer  them  to   sources   of  services,    to 
work    for  the   establishment    of   citizens    advisory    councils   where 
they    do  not  exist,    to  assist    in  the   placement    of   disabled   workers 
and   actively   to   support    community   rehabilitation  programs.      The 
experience    garnered  by   such    labor  rehabilitation   projects   as 
that    of   the   Sidney   Hillman   Health   Center  in  ^ew  York  City,    the 
New   York  City   Central   Labor  Council   and  the    Iowa   Federation    of 
Labor  should  be    widely    disseminated  and   affiliated  bodies   should 
work   closely  with   the   National   Institutes    on   Rehabilitation   and 
Health   Services   and   the   Vocational   Rehabilitation   Administration 
in   order   to   initiate   and  organize    similar  projects   wherever 
feasible." 

Finally,   it    should  be   noted   that   health   needs   and   services 
today    are   extremely    comolex.      Not    only   cannot   the   health  needs 
of   a   single    individual  be    met   by   the    services   of   a  single 
generalist;   we   have   a   woeful   shortage    of  all   types   of  health 
personnel   and   facilities. 

Organized   labor  is    becoming  increasingly    convinced   that 
those   medical  care  programs  which   are   based   on  a  team  approach, 
utilizing  the   varied   skills   and  knowledge    of   all   of  the   health 
professionals    required  to  meet   the   needs    of  the   patient,    pro- 
vide   the   highest    quality   of   care    in  the    most   efficient   manner. 
As    an  example    of  the   type    of  program  towards   which    labor  is 
moving,    let    me    cite    the    Metropolitan   Hospital   and  Clinics, 
utilized  by   the    Community   Health   Association   of   Detroit,   which 
is   sponsored  by   the   United   Automobile    Workers.      That    program 
is    staffed  by   a  number  of   full-time,    salaried  health  professionals, 
including  social   workers,   physicians,    optometrists,   podiatrists, 
physical   therapists,   nurses   and   other  appropriate   personnel. 
The   services    of  speech   therapists,    occupational  therapists    and 
psychologists   are    available   as   needed,    and  the   Michigan  Division 
of  Vocational   Rehabilitation  has    assigned  a  vocational   rehabili- 
tation  counselor  to  the   program  to  assist   those   patients   with   a 
vocationally  handicapping  condition.      All   of  these   professionals 
work  together  in   a  harmonious   manner  to  meet   the   needs    of   their 
patients.      Of  particular  interest    to  this    audience,    perhaps,    is 
the    fact   that    the    optometric    service   was   established   in  consultation 
with   representatives   of  the   American  Optometric   Association,    and 
an   audit   of  the   service   was   also    later  provided  by   the   AOA. 

I    sincerely  hope   that   there    will   be   many   more   such   programs 
in  the    future,   perhaps    organized   on   differing  models,   but   all 
retaining  the   essential   feature   of  the   cooperative   team  approach 
to  meeting  the   needs    of  the   patient. 


78 


QUESTION    DIRECTED  TO   MR.    CARROLL:      Earlier  today    it   was 
said   that    labor  union   rules   are   partially   resnonsible    for 
preventing  employment    of  the   handicapoed.      Seniority  pro- 
visions  and   requirements,    for  instance,    that   only  women   may 
hold   certain   jobs   were    cited.      Would  you   wish   to   comment? 


MR.    CARROLL:      I   know   of  no   such  provision   in   any  union 
contract    in  the   country.      The    trade    union   movement  has    done 
more    in  this    country   for  equal   treatment   for  women   than 
probably   any   other  organization   in   the    fountry    and   fought 
very  hard  against   this    concept   of   treating  women   differently 
than   men   in   the    shops    under  contract.      Now,    there    are   certain 
differences    in  job   capabilities  between    men  and  women,    and 
so   therefore,   unions  have   also   supported   state   and   federal 
legislation   which   provides   certain  protection   to  women   in 
industry  because    of   these    differences,   but   I   don't   know   of 
any  provision   of  any   union   contract   that   says    certain  kinds 
of  jobs    are    to   be    the   exclusive   property   of  women.      Now,    it 
is    true,    of  course,    that   employers    frequently   will  not   employ 
handicapped  people.      The    only   thing  the   union   can   do,    is   to 
say,    "We    insist    that   you  employ   individuals   who  have    met   the 
requirements   of   apprenticeship   training,    and   so   on   and   so 
forth."      This    applies    of   course    only  to   the   apprenticable 
trades. 

Employers    may   have    discriminated  against   handicapped 
individuals    and   refused   to  hire    them,    even   though  they   have 
a   job    available    in  the    shop   which    the   handicaoped  person   can 
perform,    because    of  the    fact   that    the   union  has   instituted 
seniority   rules   in  the   plant,    and  that    if  a  particular  job 
should  disappear  and   the    individual  performing   the    job   has 
acquired   seniority,    the    company   sometimes    is    faced  with   the 
problem  of   finding  a   job   which  he    can   do.      They   may  have   to 
restructure    that   job    so   that  he    can   do   it,   and   sometimes 
they   are   not    willing  to   go  through   the   extra  expense   necessary; 
I   gave   the   example    of  enlarging  the   numerals   on   a  machine. 
So  in  this    area,    one    can   argue   that    the    seniority  provisions 
of  union    contracts   inhibits   the   employment   of  handicapped 
people.      On   the    other  hand,    I   believe    that   the    seniority  pro- 
visions  protect   workers   who   develop   handicapping  conditions 
while   on   the   job. 

Now  the   trade   unions  fought    long   and  hard  over   the   years 
to   institute    another  kind  of  program  to  encourage   employers   to 
employ   handicapped  workers — the    second   injury    funds    or  subse- 
quent   injury    funds   which   operate    under  workmen's    comoensation 
laws. 


79 


The    research   which  has   been   done    on   the    subsequent   injury 
laws   has    indicated   that    they   are   not   effective.      I    recall  a 
study   in   Mew   York   City   by   The    Federation    for  the   Handicaooed 
on    this.      They    discovered   first    of  all   that   employers   didn't 
know  that   the    second   injury    fund  even   existed,    and  what   pro- 
tection  they    offered  to  emoloyers   that  hire   handicapped  workers, 
Secondly,    even    if  they    did  know,    they    still   wouldn't   hire 
them.      But,    frankly,    I    don't   know   of   any   situation  where   union 
contracts    or  rules    inhibit  employment    of  a  handicapped  worker 
in  a   shop. 

I    can   recall   a   very   specific   instance    of   a  vocational 
rehabilitation   counselor  calling  a   friend   of   ours    in   New  York 
City   and  complaining  about   the    fact    that    an  employer  in 
Connecticut   had   said  that  he   couldn't    give   a  handicapped 
worker  a   job  because    of  union  rules.      She    said,    "How   come, 
what    is    the   problem  here?"      Well,    he    checked   into   it   and 
found   out    that   the   employer   didn't   even  have   a   union    shop. 

I   think  we    should   face   up    to  the    fact,    though,   that 
most   of  us   have    certain   feelings    of   rejection   for  handicapped 
people.      We   have   certain   fears.      We   may  say   first   of   all 
when   we    see   this   person,    I   am  glad  that    it   didn't   happen  to 
me.      Then  we    feel  ashamed,    and  in  order  to  put   this   whole 
situation  out   of   our  minds,   we   put    them  in  an   out   of  the   way 
corner  in  a   sheltered  workshop.      I   think  that    sheltered 
workshops    serve   too   frequently   as    ghettos    for  handicapped 
people.      I  want   to  be    gentle   with  this   kind  of  criticism 
because,    of   course,    many  of  them  indeed   serve   as    valuable 
institutions   that   do  provide   extremely   important    services 
in  training  individuals  who  are   handicapped  and  also   for 
terminal  employment    for  individuals  who   are   not  employable 
in  a  competitive    situation. 


171^    Massachusetts  Avenue, N.W. 
Washington,    D.    C.      20036 


80 


MEDICAL  ASSISTANCE  PROGRAMS 
OF  THE  BUREAU  OF  FAMILY  SERVICES 

Sarah  A.  Butts* 

This   conference,    among  other  things,    recognizes   that 
limited  vision    frequently   creates   special  needs   partially- 
sighted  people   cannot   cope   with   alone.      Consequently,    it 
is   necessary   that    adequate   provisions   be   made    for  the    gamut 
of   services    required  by   this    sizeable    group. 

I   have   been   asked   to   discuss   the   present   programs    of 
the   Bureau   of  Family   Services   which   are   available   to   meet 
the    social  and  economic   needs   of   the   visually   limited.      Title 
10    of   the    Social   Security  Act — Aid  to  the   Blind — is    the   only 
legislation   that    identifies   assistance    for  a   particular 
visually-handicaoped   group.      Visually    limited  needy  people 
who   do  not    meet   the    definition   of  blindness   would  have   to 
be   included   among  the   aged,    permanently   and   totally   dis- 
abled,   families  with   dependent   children   or  the    medically 
needy.      Since    some   of   you   may   not   be   very    familiar  with  the 
Bureau,    I   will   briefly   oresent    some   information   about    its 
structure    and   function. 

Prior   to   1963,    we   were   known    as   the   Bureau   of   Public 
Assistance,    part    of   the    Social  Security   Administration   of 
the    Department   of  Health,    Education    and  Welfare.      The 
Welfare   Administration   came    into  being  in    1963   to   operate 
within   the   Department   of  Health,    Education   and  Welfare, 
under   the    direction    of  a   Commissioner.      Dr.    Ellen   Winston 
was   appointed   as   the    first   Welfare   Commissioner  and   still 
holds   that   office.      The   Welfare   Administration   encompasses 
four  agencies:      Children's   Bureau,    Office    of   Juvenile 
Delinquency   and   Youth   DeveloDment,    Cuban   Refugee    Program 
Staff,    and   the    Bureau   of  Family  Services. 

Our  Bureau  program  is   carried   on   by   575    employees,    who 
are    located   in   our  Central   Office    in   Washington,    D.C.,    and   in 
each   of   the   nine   Regional   Offices    in   different    sections   of   the 
country.      It    is    the    responsibility   of  the   Bureau   to  administer 
the    Federal-State    grant-in-aid  programs   of  public    assistance 
established   by   the    Social   Security   Act   passed   in    1935    and   its 
amendments.      There   have   been   a    series    of   such   amendments,    the 
latest    and   most    impressive   are   the    19 65    amendments   to  the   Social 

* Medical   Services   Soecialist,    Medical   Services   Division,    Bureau 
of  Family  Services,    Welfare   Administration,    U.S.    Department   of 
Health,    Education   and   Welfare 


81 


Security  Act   contained   in   Public    Law  89-97 — Title    XIX — Grants 
to  States    for  Medical  Assistance   Programs.      Title    18 — Health 
Insurance    for   the   Aged,    popularly   known   as   "medicare"    is   the 
responsibility   of  the   Social   Security  Administration. 

The    grant-in-aid  programs    administered   by   the   Bureau  are 
the    following:      Old-Age   Assistance,    Aid   to   the    Blind,    Aid  to 
Families   with   Dependent   Children,    Aid   to   the   Permanently   and 
Totally   Disabled,    Medical   Assistance    for  the   Aged,    arid   since 
January    1,    1966,    the   new  Medical   Assistance   program.      Approxi- 
mately   7   1/2    million  people   received    financial   and  medical 
assistance   under   these   programs    in  November   1965 .      The   cost    was 
then   about    $435, 710,000   per  month.      Two   million   one   hundred   and 
thirty   thousand   received   Old-Age    Assistance;    278,000,    Medical 
Assistance    for  the   Aged;    9^,600,    Aid   to   the    Blind    (the    smallest 
group);    571,000,    Permanently   and  Totally   Disabled;    1,056,500 
families   received   Aid   to   Dependent   Children   and   in  these   million 
plus   families,   there   were    3,311,900   children. 

You   can   appreciate   that   these   are   vast    programs.      They 
operate    in  fifty   states,    plus   the   District   of  Columbia,    Guam, 
Puerto  Rico   and  the   Virgin   Islands,      Federal    funds   for   financial 
assistance,    medical   care   and   administration   costs   are   allocated, 
according  to   formulas,    to  each   of   these   jurisdictions   and   must 
be   matched  by  state   appropriations.      To  be  eligible   to   receive 
these    federal   dollars,   each    of   these    jurisdictions   must   meet 
certain   federal   requirements,    one    of  which   is   that    each   submit 
a   state   plan   describing  their  public   assistance   programs   and  how 
they  will   be   carried   out.      I   will   mention    only   a   few   of  these 
requirements.      The   oublic   assistance   program  must    be    statewide 
and   administered   or   supervised  by  a   single    state   agency;    the 
state   agency   must    offer   opportunity   to  anyone   wishing  to   apply 
and  act    on    such   applications   with   reasonable   promptness;    records 
must    be   confidential;    the   agency   must    determine    that   the   people 
who  are   aided  are   needy   according  to  the   uniform   standard   of 
the    state,    that    is,    their   "income    is    insufficient    to  provide    a 
reasonable    subsistence   compatible    with   decency    and  health." 
Applicants    for  Aid  to   the   Blind  must   have   an   examination   by  a 
physician    skilled   in  diseases   of   the   eye    or  by   an   optometrist, 
whichever   the    individual   may   select.      The    1962   amendments   to 
the   Social   Security  Act,    among  other  things,   encouraged  better 
care    for   children   in   the   Aid   to  Families   with   Dependent   Children 
program  by   requiring  that    state   public    assistance   agencies   make 
a   social   study   of  each   child   to   determine    his   needs    and   promote 
the   welfare   of  these   children   and  their  families.      The   child's 
health  situation    is   a  part    of  this   study. 

It   has    always    been   possible    for  public   assistance   agencies 
to  provide    medical   care,    but    there   was  no   specific   allocation   of 
money   to  help   with  this   until   1950,   when   federal   matching  was 
first  permitted   for   vendor  or  third-party  payments   for  medical 


82 


expenditures  in  behalf  of  welfare  clients.   The  cost  for  the 
first  full  year  of  operation  under  that  authority  was  $70.5 
million.   Our  population  has,  of  course,  increased  during  the 
last  15  years  with  public  welfare  caseloads  reflecting  that 
growth.   States  are  now  spending  more  than  a  billion  dollars 
a  year  in  vendor  medical  payments  for  needy  people.   The  1965 
amendments  expand  medical  care  provisions  for  this  part  of 
our  pooulation.   By  1975,  states  will  be  expected  to  provide  for 
the  medical  needs  of  all  their  people  who  cannot  afford  necessary 
care.   States  in  the  past  have  been  able  to  decide  the  kinds  of 
medical  services  they  will  provide  as  well  as  the  amount  and 
period  of  time  they  will  pay  for  care.   This  resulted  in  un- 
eveness  as  you  know — old  peoole  received  more  comprehensive 
care  than  children,  who  sometimes  got  none  or  very  little. 
The  blind  and  disabled  were  somewhere  in  between.   The  Federal 
Government  contributed  its  share  up  to  the  maximum  oermitted 
by  the  legal  formula,  whether  it  was  a  generous  or  limited 
state  program.   If  the  state  included  diagnostic  and  preventive 
services,  glasses,  low  vision  aids,  etc.,  we  would  match  these 
expenditures  provided  the  suppliers  were  licensed  or  recognized 
under  state  law. 

When  Medical  Assistance  for  the  Aged  (Kerr-Mills)  became 
effective  October  1,  i960,  the  legislation  carried  a  list  of 
twelve  medical  and  remedial  care  services  states  might  provide 
to  eligible  oeople  over  65  who  could  not  afford  to  meet  their 
own  medical  care  expenses.   One  of  these  items  was  "Diagnostic, 
Screening  and  Preventive  Services."   States  again  could  offer 
all  of  these  twelve  medical  services  or  less;  but  for  the  first 
time,  they  had  to  give  some  institutional  care  and  some  non- 
institutional,  for  instance,  hospitalization  and  nhysicians' 
visits  in  the  home  or  office.   This  was  a  beginning  to  establish 
some  balance  between  the  kinds  of  medical  services. 

The  big  advance  in  broadening  medical  coverage  in  oublic 
assistance  came  last  summer  with  Title  19-0rants  to  States  for 
Medical  Assistance  Programs.   It  establishes  for  the  first  time 
a  single  and  separate  medical  care  program  in  contrast  to  the 
medical  care  provisions  covered  under  the  existing  five  different 
titles  of  the  Social  Security  Act.   Another  important  provision 
is  that  medical  care  may  not  be  denied  to  those  who  are  otherwise 
eligible  but  do  not  meet  the  residence  requirements  of  the  state. 
Title  19  enumerates  fifteen  types  of  medical  services  a  state 
may  provide  for  eligible  needy  peoDle.   Besides  inpatient  and 
outpatient  care,  skilled  nursing  home  services,  dental  and 
clinic  services,  it  includes  "eyeglasses  prescribed  by  a  ohysician 
skilled  in  diseases  of  the  eye  or  by  an  optometrist,  whichever 
the  individual  may  select"  and  "other  diagnostic,  screening, 
preventive  and  rehabilitative  services."   Furthermore,  states  are 
expected  to  begin  paying  the  reasonable  costs  of  care,  which 
should  end  bargain  basement  or  second-class  medical  care.   By 
July  1,  1967,  reasonable  costs  must  be  paid  for  hospitalization. 


83 


States   have    some   wide    options   with   resoect   to   implementing 
Title    19,   except   that   after  December   31,    1969,    unless   they    oper- 
ate   under  its   provisions,    the   Federal  Government   will  not    match 
the   cost    of   any   of  their   vendor  medical  care   under  the    individual 
public   assistance    titles.      January    1,    1966,    was    the   beginning 
date    for  this   new   medical   assistance   program  and   several   states 
are    already   underway.      It    is    likely   that   by  the   end   of   this 
year,    some    twenty-one    states   will  have   Title    19   programs. 

Between   January    1,    1966   and   July    1,    1967,    a  state,    if   it 
chooses,    may   offer   only   some    institutional   and   some   non-institu- 
tional  care.      But   after  July   1,    1967,    the    inclusion    of  at    least 
five    basic   services    are    required.      These   are:      1)    inpatient 
hosoital    services;    2)    outpatient   hosoital   services;    3)    other 
laboratory   and   X-ray   services;    4)    skilled  nursing  home    services 
for   individuals   21   years    or  older;    and  5)    ohysicians'    services, 
whether   furnished   in   the    office,    the  patient's    home,    a  hosoital, 
a   skilled  nursing  home    or  elsewhere.      Also  effective   July   1,    1967, 
states   must   extend   medical   assistance   to  all   children   under  21 
who   would   be   eligible    for  Aid   to   Dependent   Children   whether   or 
not    they   are    in   school.       (There    are   some    other  provisions   in   this 
title,    but   they   are   not    closely   related  to   our  subject.)      The 
cases    receiving   financial   assistance   must    all   be  equally  covered 
by  the   provisions   of  the    states'    medical   assistance   plans. 

At   the    same    time    or   later,    a   state    can    include   the    marginally 
needy   group   who   do  not   need   financial   assistance    for   regular 
maintenance   but   cannot   afford  to  pay    for  their   medical   care. 
This    is    an   improvement   because    it  enlarges    the    group   who  will 
benefit    from  the   new   legislation.      There    is,   however,    the    re- 
quirement  that   to  be   eligible,    the   marginally  needy   people    must 
also    fit    into  one    of   four  presently  existing  categories.      That    is, 
they   must   be   65    or  over  as   in   old-age    assistance,    meet   the    state's 
definition   of  blindness    or  permanent   and   total   disability   or  criteria 
for  Aid   to   Dependent   Children.    States,    if  they    choose,    may   cover  all 
children   under  21   in   families  who   are   unable    to   afford  medical 
care.      However,    people    over  21   and  under  65    who   are   neither 
blind  nor  permanently   and  totally   disabled   cannot   receive    med- 
ical  assistance    under  Title    19,    unless   they   are   parents   in   medical 
needy   family   groups.      Their  medical   costs  would  have    to  be   paid 
for  entirely   out    of  state   and   local   funds    as    many   states    do 
already.      States   must    move   between  now   and   1975    to  extend   com- 
prehensive  care   to  all  needy  people,    so   eventually   this    segment 
of   our  population   will   receive   equal   medical  benefits. 

The    scope   of   medical   care   a   state   provides   should  be   both 
comprehensive    and   of  high  quality.      Hospitalization;    clinic    and 
outpatient    services;   Dhysicians'    visits   in   the    office,    home, 
hospital,    a   skilled  nursing  home    or  elsewhere;   prescribed  drugs; 
dentures;   prosthetic   devices;    skilled  nursing  home   services,   home 


84 


care    services;   eye    glasses;    low   vision  aids;    screening,   preventive 
and   rehabilitative    services    and  necessary   transportation  expenses 
to   obtain   medical   care   can   all   be    included.      States   with   adequate 
financing  can   now   afford   to  offer  such  a    full   scope   of  care    to 
both   the    cases    receiving   financial   assistance   and   those   whose 
marginal   income   will   not   cover  medical   expenses.      Low  income 
states   may   not   be   able    to  move   to   this    broader  medical  assistance 
program  before    1970,    when   they   will   have   to   do   so    or   lose    federal 
dollars.      Some    may   come    in   only   with    the   people   eligible    for  a 
money  payment   and   later  on  add  the  marginal   group. 

As   I   mentioned  earlier,    the   new   legislation,    among  other 
things,   equalizes   the    medical   services  provided   so  that   all 
eligible    recipients   are   entitled  to  the   same    scope   of   care,    in 
the    same    amount    and   for  the    same   period   of  time.      When   states 
come   into  Title    19,    if  they  include   physicians'    visits    (and 
after  July   1,    1967,   they   are    obliged  to)    all  their  aged    (if  not 
otherwise    covered)    blind,    disabled  and  Aid  to  Families   with 
Dependent   Children    clients   will   be   able   to  get    this    service.      A 
state    may   cover  the   marginally  needy   as   well;    although  here, 
the   state   has   another   option:      they  may   offer  a   lesser   scope    of 
medical   services   to  the    latter  than   to  their  money  payment   cases, 
but  not    more.      If  they  provide    glasses    for  old-age   assistance 
recipients,    it   will  be   necessary   to  supply    them  for  the   permanently 
and   totally    disabled   and  Aid   to   Families   with   Dependent    Children 
cases   too.      If  they   include   ambulance   and  transportation   costs, 
they   must   be    "across  the   board"   too. 

In   addition   to   financial  and  medical   assistance    for  eligible 
needy  people,   the   public    assistance   program,    operative    in  every 
county,    some    3,000   across    the   nation — also  provides   social    services. 
These   are   needed   to  help   our  recipients,    insofar  as   oossible    to 
reach   their  maximum  level    of   functioning.      The    goals,    of  course, 
vary   with   the    age    of  the   client,    his   educational   and  occupational 
background,    the    state    of  his   health  and,    last    but  not    least,    what 
he   wants    for  himslef.      To  be   more    specific,    we    are    anxious   that 
the    children  in   our  program  grow   up    in  harmonious   households 
with   good  health  and   opportunity  to   receive   the    schooling 
necessary   to  prepare    for  suitable    work;    that   the   underemployed 
and  unemployed  become    fully   self-supporting;    that    the   handi- 
capped  are    directed  to   the   proper  rehabilitation   agency  which    is 
usually   the   nearest    office    of  their  State   Vocational   Rehabilita- 
tion  Agency;   that   the    aged   and   chronically   ill  be    restored,    if 
possible,    to   the   extent    they   can    care    for  all   or  at   least   part 
of   their  personal  needs   and  helped   to   maintain  this    level   of 
functioning.      In   other  words,   public   assistance    funds,   program 
and   staff  services    are    for  the   purpose    of  maintaining  and 
strengthening   family   and   individual   lives.      This    is    indeed  a 
tremendous    commitment   and  one    in   which   we    cooperate   with   many 
other  organizations,    both   public   and   voluntary.      I   will   identify 
a    few. 

85 


I  previously   referred  to  the  Vocational   Rehabilitation 
Administration,    which  has   statewide    coverage.      They   finance   a 
substantial   amount    of  eye    care    for  public    assistance    recipients 
with   whom  they   work.      The   programs    of  the   Children's    Bureau  are 
another  important    resource    for  welfare    recipients.      They    include 
Maternal   and  Child  Health,   Child  Welfare    and  Criopled  Children 
services.      State    and  local  health   departments   and   school   health 
programs   also  provide   essential  health   care    for  many  public 
assistance    clients.      The   U.S.    Public   Health   Service    through   its 
leadership    and   funds,    including  money    for  special  project   or 
demonstration    grants,   improves   and  extends   health   and  medical 
care   opportunities    for  our   citizens,   needy   and   otherwise. 

As  you  realize,   public   assistance    is    "a  cradle    to   the    grave" 
resource    for  needy  people    who   meet   the   eligibility   requirements    of 
their  state.      I   am  not    sure   how   many  babies   come    to   your  attention, 
but    from  the   pre-school   age    group   up   to   the    very  elderly,    you 
see   the   same    life    span   we    do.      And   some    of  the    same   problems   that 
beset   people    may   come    to  your   attention,    directly  expressed   or 
sometimes   only  hinted  at.      I    can   think   of  a   few   that   are   not 
uncommon,    although   I    realize   a   more   extensive    list    might    come 
from  this    audience,   perhaps   as  part   of  the   buzz   sessions   and 
workshop    discussions. 

It   is   important    that    you  know  the   scope   of  medical   care 
your  state  public   assistance   agency  provides.      If  your  patients 
cannot   afford  eye    care,    they   may  not   know   it   might  be   paid  for 
by  public  assistance.      You   certainly   cannot   and   should  not    de- 
cide   whether  they   are    likely   to   be   eligible;    only  the   agency 
can   make    that   determination.      But   you   can   tactfully   suggest    they 
consider  discussing  their  circumstances   with   the    local   welfare 
department.      Even  though  they    may   not    be   eligible   at   that    time, 
an   important   part    of   the   agency   intake    department's    responsibility 
is    to   direct    such   people   to   another   resource    in   the    community 
that    can   provide   the   service.      Although   there    is    a   certain  amount 
of  publicity   about    the   help   available    from   community   agencies, 
very    often  it   does   not   reach  many   of  the   peoole    who  need  the 
services    or  even   if  the    word   gets   through,    such   peoDle   have 
only   vague   Ideas   of  just   where   they    can   obtain   assistance. 

Trouble,   especially    for  poor  people,    is    seldom  confined  to 
a   single    difficulty.      They   may   identify   only   the    most   pressing 
need   at   a  particular  time,    or  mention   the    one    thing  they   believe 
the  person   they   are    consulting  can  help   them  with.      Thus,   needing 
glasses    or  treatment   they   cannot    afford  may   be   but    one   aspect    of 
several   serious  problems   eye   attention   alone    cannot    solve.      A 
referral   may   result    in  the   provision  of  a   variety   of  services. 


86 


The   effect   of  a  severe    visual   limitation   as   you  know,    is 
different    for  each  handicapped  person.      Fortunately,    a  good 
many  of  this    group   understand  the   reason   for  the   impairment 
and  can   live   with   it,   making  a   good  adjustment   to  the   social, 
educational  and  vocational   limiations   the  eye    difficulty   im- 
poses.     These   people   may  be   poor,    have   a  marginal   income    or  be 
well   off.      However,    the   public    assistance    agency   is    set   up    to 
serve   the   poor  and  those   who,   because    of  inadequate    resources, 
are    likely   to  need   such   assistance. 

So  you   may   think   of  the   public   agency   as   a   resource    for 
your  patients  when  you   find  they   seem   to   require    any   health   or 
medical   services.      Your  examination   may    reveal   the   oresence    of 
illness    or  disease    that    is   not    receiving  attention.      We   are 
anxious   to  have    our   families   accept   preventive    care  as   well   as 
medical   intervention   to   forestall   the  progression   of  ill  health. 
Parents,    for  various   reasons,   may  not   recognize    defects   in   their 
children   that   do  not   cause    discomfort   or  think   they   do  not    matter 
and  will  be   outgrown.      If   such   parents   come    within   your  pur- 
view,   there   may  be   an   appropriate    opening  to   suggest   that    correct- 
ion   of   the    defect   is    important   and  how   the   necessary    service   can 
be   arranged. 

Progressively   serious   eye    conditions  pose    great   concern 
to   the  patient  and  also  his    family.      If  the   patient    is   a  wage 
earner,    he   or  she    may  have    to   give    up   their  customary  work   and 
need   a   referral   to   public   assistance.      If  it    is    an  elderly  per- 
son  living   alone    or  responsible    for  the   care    of  others,    they 
may  no    longer  see   well  enough   to   do   the  household  tasks   safely. 

They   could  ask  the   welfare    department   about    other   living 
arrangements   such   as   a   boarding  home    or  similar  protective    care, 
something  that    is   now  needed  but   they    cannot   afford. 

There    are    recipients    of  public   assistance,    usually   the 
elderly,    who — like    the   elderly   in  better  economic    circumstances — 
just   cannot    accept   the    fact   that   properly  prescribed  and   fitted 
glasses   will  not    "make    their  eyes    as    good  as  new".      They    are 
prone   to   go    from   office   to   office    believing  somebody,    somewhere 
will   supply  the   pair   that   will   have   the    desired   magical   result. 
Professional   time   and  tax    funds   are   wasted  during  such    searches. 
If  welfare    clients  with    this   pattern   come   to  your  attention,    I 
suggest    they   be    referred   to  their  caseworker.      It   is    the    latter 
who  knows   this   person   and   can   take    time   to   sit    down  and  talk 
through  the   basic    difficulty,   namely,    the   meaning   of  the   eye 
problem  and  the    difficulties   it   poses    for  the   person.      Help   in 
these   areas   should  result    in   a  more    realistic   acceptance    of  the 
visual   handicap   so  energy   can   be    spent   more  productively   in 
making  the   best   use    of   remaining  sight,    rather  than   denying  the 
existence    of  the    impairment. 


87 


If  you  follow  the  clues  your  patients  offer  and  express 
interest  in  the  difficulties  they  face,  it  will  often  be 
possible  to  discover  that  financial  and/or  medical  needs  are 
pressing. 

Then  you  may  find  the  timing  is  aporopriate  to  inquire  if 
they  would  not  like  to  discuss  these  matters  with  their  local 
public  assistance  agency.   If  they  agree  but  do  not  know  the 
location  or  when  to  go,  this  information  can  be  easily  obtained. 
If  direct  advice  is  sought,  of  course,  a  direct  answer  can  be 
given.   The  patient  must  make  his  own  decision;  to  apply  now 
or  later  or  not  at  all,  but  whatever  the  choice  turns  out  to 
be,  it  is  the  rare  individual  who  will  not  appreciate  this 
evidence  of  your  concern  for  his  situation. 


Washington,  D.C.    20201 


88 


QUESTION!   DIRECTED  TO    MISS    BUTTS:      What    standards   will   be 
used   for  evaluating  the   quality    of  medical   care   orovided  under 
the   new  Dublic   assistance   orogram? 


MISS   BUTTS:      Congress   intends   this    care    to   be    of  high 
quality   and   included  certain   references    in   P.L.    89-97  to   give 
such    support.      One    of  these    requires   the   establishment    or 
designation    of   a   state   authority   to  establish  and  maintain 
standards    for  the   public    and  private   institutions   where 
recioients   of  medical  assistance    will   receive    care    or 
services.      Another   is   the   payment   of   reasonable   costs    for 
inoatient   hospital   services    at    least  by   July   1,    1967. 
More    generous    federal   sharing   of  medical   care   expenditures 
will  allow   states   to   increase   payments  to   other   suppliers 
as   well,    which    in   turn   will   make    it   easier   for  our  clients 
to   obtain   quality   care.      This   will  help   to  eliminate    the 
gap   between   the    cost    of  service    and   the    amount    of   reim- 
bursement  that   has   too   often   been   the   pattern   in  the  past. 

The    Federal   Government   will   meet    75   percent   of  the 
states'    outlay    for  the    salaries   and  even  the   training  of 
skilled  professional   medical  personnel   and   supporting  staff 
of   the    state   who   will   administer   the    state   medical   assist- 
ance  program.      This   will   insure    qualified  direction   and 
leadership    for   our  programs.      Regular  50   percent   matching 
of  other  administrative   costs   of  all  public   assistance 
programs   is   in  addition  to  this    75   percent. 

Each   state,    as  part   of  their  medical   assistance   plan,    must 
set   up   in   their  central   office   a   medical   unit   with   a   full-time 
director  with   appropriate   experience    in  a   recognized  medical 
care    or  health   services  program.      If  this   person   is  not   a 
physician,    then   there    must    be   provided  at    least   half-time 
services    of  a  physician.      There    must   also  be   a   full-time 
graduate    social  worker,    a  part-time    dentist   and  pharmacist 
and   such   additional   technical  and  professional   staff  as 
necessary.      As   the   program  expands,    there   will   be   similar 
medical   units   in   regional   or  local   offices. 

A   State    Medical   Advisory   Committee    representative    of   the 
health   professions   and  consumer  groups    is    required   to   meet 
regularly   to  evaluate   the  program  and  advise   the   welfare    dir- 
ector about    its   operation.      Each    state    must    submit   regular 
reports   to  the    federal   level   and   develop   satisfactory   methods 
for  continually  evaluating  their  medical  assistance   plan. 

I    might   add  with  respect   to   standard-setting,    there   is 
a  timetable    to   insure    that   our  Title    XIX  standards    for  hospitals, 
outpatient   hospital   services,    skilled  nursing  homes,    laboratory 


89 


services,   etc.,    will   be   the    same    as   those    required   by 
Title    XVIII    for  the   elderly. 

The    Bureau  has    responsibility ,    delegated  through   the 
the   Secretary   of  Health,   Education   and  Welfare    and  the 
Welfare    Commissioner,    to   follow   state   medical  care   pro- 
grams  in  these   as   well   as    some    other  ways   to  make    certain 
they    carry  out   both    "the    soirit   and   letter"    of  the    legis- 
lation. 


90 


COMMENTS    BY    RESOURCE    PANELIST 


William  B.    Parsons* 


I   want   to  express    our  appreciation    for  the   invitation   to 
participate    in  this    conference.      In    discussion   that    I   had  with 
some    of  the   particioants ,    I   was    asked  to   comment    on  the   activity 
of   the    Neurological   and   Sensory   Disease   Service    Program  and 
specifically  to   comment    on   our  activities    in   the    vision   area. 
We    are   primarily   concerned  with   activities    in   the    areas    of 
vision   which    lead   to  orevention    of   blindness.      At   the  present 
time    we   are    involved  with    glaucoma   detection;    diagnosis,    treat- 
ment  and   follow-up.      Another  area    of  concern   is    amblyopia 
detection.      We   are    stimulating   detection  activities    among 
preschool   children   which   include    diagnosis    and   treatment. 

There    is    some    controversy   on   the    advisability   of   screening. 
At   this    time    in   view   of   the    information   available    to  us,   we   are 
maintaining   our  interest    in   these   areas   and  will   attempt    to 
clarify   the    issue    and   work   with   the   eye    specialists   in  achiev- 
ing prevention    of  blindness. 

Another  activity   of  interest    is   the   prevention   of  trau- 
matic  injury   to   the   eye.      This    activity    is    related   to   control 
of  environmental   conditions    and   involves    coordination  and 
cooperation   with   the    Division   of   Accident    Prevention,    the 
Society   for   Prevention    of   Blindness,    and   others   who   are 
vitally    concerned.      We   are    involved   to  a   limited  extent 
with   the   partially   sighted,    which   we   are    discussing  here 
today.      We    are   interested   in   working  with  those   people 
who   have   this    as    a  concern.      However,    at    the   present   time 
we    are    only   in   a  position   to  provide    moral    suoport.      Later, 
we   hope    to   be    able    to   give    more   than   moral   support;    when  we 
do,    it    will   be    in   cooperation   with   the   Vocational   Rehabili- 
tation  Administration,    the   Welfare   Administration,    the    Library 
of   Congress,    and   other   organizations    and  professional    groups 
such    as   yourself. 


*Assistant    Chief    for  Program  Development,    Neurological   and 
Sensory   Disease   Service    Program,    Division    of   Chronic    Diseases, 
Bureau   of   State    Services,    Public   Health   Service,    U.S.    Deoart- 
ment    of  Health,    Education   and   Welfare,    Washington,    D.C.    20201 


91 


COMMENTS    BY   RESOURCE    PANELIST 


Keith   Tennis  on* 


I    didn't    come   here    to   talk,    I    came   here    to    listen. 
I    will    say   a   few  things;    and   if  there    are    any   questions 
later,    I   will   be    delighted.      I   have   never   su^pcested  that 
large   type    is    any   substitute    for  magnification.       It    appeared 
from   research   that   it    might   help   some   people    to   make    up   their 
minds    as   to   what   kind  of  magnification   they   wanted   in    terms 
of  a  new  kind  of   book.      The   books    are    8-1/2"    x    11",    because 
enlargement    of   the   existing  oublishing  oage   produces    a  book 
that    size. 

The    title    selection    in   the    first   thirty  titles   was 
deliberate.      Fifteen   of  the    first   thirty  were    selected    from 
those    adult   classics   that   are    annually   assigned   at    the 
junior  high   and  hie;h   school   reading   level.      This    is    be- 
cause   the    school   system   said   it   was   their  deep   wish  to 
keep,    as   much   as   possible,    all   the    students    in   the    same 
class    in   their  required   reading  assignment.      The    other 
fifteen   books    are    more    or   less    generally    recreational   adult 
titles.      All   of   the   books,   almost    without   exception,    bear 
the    double    star   of   the    standard   catalog  and   the    double 
starred  entries   in  the   catalog  which   all    libraries    use    are 
awarded  very   soaringly   by   a   library    committee   each   year. 

The    use    records    of  the   book    so    far  Drove   almost   nothing. 
The    first    group   of  ten   was    completed   only    last   September,    so 
I    can   tell   you   very    little,    and   I    am  not  even    sure    of   that. 
However,    the   circulation    figures   were   enough    so   that    my 
Board   of  Directors   said,    "How   many   titles    would  you   like 
to   do  next    year?"      And   I    said   "fifty",    and   they    said, 
"fine",    and  this    represents   the    commitment   of   somewhere 
around   $300,000,    so  I    felt   they   must   know   something  that 
I    didn't. 

In  the    school    systems,   they    are   beins;  used  not   only   by 
special   teachers    but   by   a   grouo    of   reluctant    readers   who 
have   no    visual  problem  whatsoever.      They    are    also  bein^ 
used  by  some   extremely   advanced   third   and    fourth    e;rade 
readers  who   are    tired   of  Dick   and  Jane,    but    who    resoonded 
to   a   more    comfortable    size    type. 


*President,    Keith   Jennison   Books,    Inc.,    575    Lexington   Avenue, 
New  York,   New  York  10022 


92 


Someone   said  that   these   books   may   be    good   for  tired 
eyes,   but   are   bad   for  tired  hands.      They    are    library   bound, 
reinforced,    which  add  weight   to  the   books;   and  book-making, 
I    suspect,    is    like   politics,    the   art   of   compromise.      They 
are   physically   about  as   good  a  book   as   the   professional   book 
publishing  world   can   create   at   the   price    which   is    being  asked, 

I   wish  to  thank   all   of   you   for   the   advice   and  encouragement 
that    you  have    given   me    over  the    last   couple    of   years. 

QUESTION   DIRECTED  TO   MR.    JENNISON:      This    question   Mr. 
Jennison   can   answer   in   record  time.      Where    can   I    get    the 
title    list   of  the   Current    30,   and  next    year's   50   books? 

MR.    JENNISON:      On   the    table    outside    is   the    list   of 
the   20  that   are   available  now;    I   have    got  a   list   of  the 
10   for  April   and   May  with  me   because    it    is    a  question   of 
what   order  we   will   publish  them.      I   have    a   list    of   the 
balance   of  this    year's   books,    but   I    cannot    show  it   because 
I   have   not   got   the    contracts   finished  with   the    owners. 
Anyone   who   is   interested   can   pick   those   up.      There    is    also 
a   reprint    of  Saturday's   Review  article    on   the   way  that 
this    came   about. 

If  I   can  have    ten    seconds— another  thing — the    librarian 
is   not    tired   of  being  a    librarian,    she    is   tired   of  not    having 
enough   money.      I   have   traveled   25    major  cities    and  talked   to 
the    chief   librarians   in  all   of  these   cities.      There   are   a 
lot   of  ways   a   librarian — waiting   for  Congress   to  act — by 
going  to   the    local   Lion's   Club   and  saying  that    I   need   so 
much   money   for  a   special   library  project    this   year,    can 
get    it   up. 

Tomorrow  morning  we  are    going  to   talk   in   some    detail 
about   the   possibilities    of   the   American   Optometric  Association's 
Committee    on   Aging  making  some    of  these    materials   available 
in   places   where    the    librarian   would   love  to  have   them 
and  doesn't   want   to  wait   until  money   comes   from  Washington. 


93 


COMMENTS    BY 


J.    Arthur  Johnson* 


I   want    to   give    you   just   a  thumbnail   sketch   of  the    types 
of   services    that   are    available    in   an    agency   such   as    the 
Columbia  Lighthouse    for  the    Blind.      It   would,    in    turn,    give 
you   some    idea  of   the    resources    in  your   own    community,    or 
somewhere   near  you,    to  which   you   may   turn. 

There    are,    in   most   major  cities,    agencies    such   as   the 
Lighthouse,   which   is    a  non-profit   agency   operated   by   a 
volunteer  Board  of  Trustees.      In   other  communities,   where 
non-profit    agencies   have   not   been    developed,    you   will   find   that 
the    state's   welfare,    or   rehabilitation   agencies,    themselves 
have    done    a  oretty   good  job   in   establishing  various   types 
of  service   programs.      Usually  these    state   programs  will 
maintain   branch   offices    in    larger  towns    and  county   seats 
within   the    state. 

The    Columbia   Lighthouse    operates   a   sheltered  workshop, 
which   is    a  transitional   type    of  shop.      At    least    is    is    our 
objective   to  have    it    as    a  transitional   shop.      We    don't    feel 
that   every   blind  person   or  partially   sighted  person    should 
necessarily   have    to   stay   in  the    sheltered  environment   over 
a   long  period  of   time. 

In   the    shop    at    least    75   percent    of  those   persons   engaged 
in  direct    labor  operations    fall   within   the    "legal   definition" 
of  blindness,   namely   visual   acuity  which   does   not   exceed  20/200 
with   the   better  eye   with   correction,    or  where   the    field  is 
restricted   to   20°   or   lesser  angle. 

There    is    a   requirement   in  the    regulations   pertaining 
to   the   Wagner-O'Day   Act,   which   stipulates    that   the    govern- 
ment  will   purchase    from  workshops    for  the   blind  those   items 
which   the   workshops    can   make    in   sufficient   quantity,    and   at 
an   acceptably  quality    level   and  at    a   fair  market   price.      When 
workshops    for  the   blind   started  out    they   produced   only    tradi- 
tional  items    such   as   brooms   and   mops.      Today,    there    are    some 
65    items   on   a   schedule    of  blind-made   products,   and   only   one 
organization  has    government    purchase   priority   over  workshoDS 
for  the   blind,   namely,   Federal  Prisons.      Prisons    do   operate 
industries    and  where   they   are    making  items    used  by   the    govern- 
ment,   the    government    first  turns   to  them   for  those    itemsi  which 


^Executive    Director,    Columbia   Lighthouse    for   the   Blind 

94 


they  Droduce.      If  orisons   are    unable    to   deliver,   they   will 
clear  the    item,    and   government   purchasing  people    then   turn   to 
workshops    for  the   blind.      Throughout   the    country   there    are 
some    ^45 0 0  oeoole    today   employed   in   about    70   workshoos   which 
participate    in   this    government   purchasing  program.      There 
is    a  non-profit    agency   in   Mew  York,    National   Industries    for 
the   Blind,    which    receives    requests    for   goods    and   in    turn 
allocates   orders   to  various   workshops.      For  example,    the 
Columbia   Lighthouse    makes    the    government    issue   necktie. 
Part    of   the    consideration   as    to  where   the    allocation   goes 
is    the    delivery   point. 

There    are    three    workshops    for  the   blind  throughout   the 
country   which   oroduce   the   neckties,    and  allocations    depend 
to   a    large   extent    as    to   where    they    are   needed.      The    average 
wage    in   the    some    70   workshops    last  year  was    around   $1.39 
per  hour,    so   they   are   not  necessarily   "sweat  shooe" .      They 
try   to   gear  their  pay    rates    to  the    going  rates    for  similar 
ooerations   in   their  own   communities.      This    is    a  major   rehab- 
ilitation   service. 

It   is    very   interesting  to  note    that   there   has   until 
recently  been   a   gap   in  the    thinking  between   those   people 
running  "rehab"    centers   and   those    running  workshops.      Lately 
it   has   been   recognized  that   work   is    an   important    factor  in 
rehabilitation,    which    fact   has  not    been   recognized  earlier. 

Other  services   you  would   find   in  agencies   such   as   the 
Lighthouse   are    specialized   rehabilitation   services.      For 
example,    a  person  who    loses   his   sight  becomes   immobile    and 
can't    do    anything  until  he   becomes    mobile   again.      The   use 
of  the   white    cane    is    a  highly  specialized  technique.      It 
doesn't    involve    just   taking  a   cane    and  putting  it   into  a 
person's   hand  and  saying  "You  have    it".      It   takes  patience 
and  extensive    training,   not    only    in  the   technique    of  using 
the    cane,    but    such   things    as   identification   of  sounds  and 
smells,   and   flow  of  traffic  and  other  kinds   of  sound.      It 
involves   learning  to   recognize    voices,    and  developing   other 
senses    so  that   maximum  use    is   made    of  them. 

There    are    many   techniques    of  daily    living.      For  example, 
you  pick   up   your  phone   and  dial   the   number.      The   blind  person 
must    memorize    the   position  of  the    letters    and  numbers   on   the 
dial  before    he    can   make    a   call.      The   blind  woman   or  man   who 
loses   his   sight  or  her  sight   is    taught  how   to   keep   house,    how 
to   dress,   and  what    colors   to   wear,    and  so    forth.      During  this 
period,    there    is    an   on-going  of  evaluation   of  his   skills, 
aptitudes   and  interests.      He    finds   out   whether  he    can   work 
with  his   hands — whether  he   has    any    fear   of  machinery — whether 
he    is    interested   in   working  with  machinery    or  tools.      Psycho- 
logical evaluation   is   another  aspect.      These   are    some    of  the 


95 


things   which    go   into  a   rehabilitation  program  carefully    designed 
to   help   the   person   minimize    as   many   as   possible    of  the   problems 
created  by   loss   of  sight   and  to  try    to   get   him   to    function   as 
near  normally   as   possible. 

In    community   or  social   services,   you  will    find  professional 
social   workers   and   other  specialists   who  will   spend   much   of 
their  time    in    the    community  with   the   kinds    of   families    about 
which   Miss    Butts   was   speaking.      Families    and   individuals   on 
welfare    rolls   have    many,   many  oroblems.      Many   of  these   persons 
become    real   "pros"    at   working  both  ends    against   the   middle, 
and   will  have    several  agencies  working  on   the    same   problems 
at    the    same   time. 

On   the   other  hand,    agencies   will   sometimes    fail   to   do 
their  jobs  properly   and  promptly.      This    results   in   the 
individual's    getting  tired  of  waiting,    so  he   goes   "shoooing". 
Less    aggressive   persons   become    discouraged   and  withdraw.      They 
get    lost. 

They   shouldn't    get    lost,    so   if  there    is   a  way   in  which 
you,    as   optometrists,    when   the   prognosis    for  a  patient    is 
poor,    can   get   them  into   the   hands   of   an   agency    specializing 
in  services    for  the    visually   handicapped,    do   it    fast.      It 
will   be    far  easier  to   make    adjustments.      It   is    tough   to   get 
these   people   out    of   their  shells. 

There    are    usually   some    services    for  children   In  a   community 
or  within   the    state.      Some   public   schools    do  have    braille    and 
sight-saving   classes.      Some   have    sight-saving   classes   alone. 
Some    don't   have    any   special   classes.      In   some    instances   the 
parents,    for  religious    or  oersonal   reasons,    send  the    children 
to  private    or  parochial   schools.      When   there    is    one   handi- 
caoped  child  with   sighted   children,    the    school   cannot   be 
expected   to  have    special   staff   or  equipment.      Roughly,    these 
would  be   services   you    could   find   in   communities    around  the 
country,    and  I    suggest   that   if  you   are    in   a   larger  city   that 
you   make    inquiries;   and   if  possible    visit    one    of  these   agencies. 
Certainly   they  would  be    glad  to   send  a   representative    over   to 
your   office   to    give   you   background  to  help  you   to  know   of  this 
resource    and  other  community   resources. 

One    of   our  major   functions    is    not   to   try   to  be    all  things 
to   all  visually  handicapped  people,    but   to   find   in  the 
community   the    very   best   services   that    can   be    obtained  which 
would  help   that    person   meet    a  oarticular  problem.      For  examole, 
if   there    is   a   family  problem  where    in   the   Family    Child   Agency 
would  be    the    logical   agency,   we    feel   that   the    referral   should 
be   made    to   that    agency  because    it    is    a   family  oroblem.      If   they 


96 


need  some    orientation   about   how  blindness  may   affect   the 

problem,   we   can    give   it  to  them,    but  they  do   the   counseling 

and  they    get    into  the   problem  on  the   same  basis    as   they 
would  without  blindness. 

Most   of   these   agencies    serving  visually  handicapped 
persons   have    at   their   fingertips   the    information   regarding 
resources   in   the    community  which  will  enable   you  to   make   a 
referral  most   directly   to  the   place   where   you  think   the 
patient    should   go,    thus   avoiding  the   possibility   of  having 
him  run    from  place    to  place   without    results. 

Perhaps    I've    taken   more   time   than   I   should  have,    but    I 
did   feel   it   was   important    for  you  to  be    aware    that    almost    any- 
where  you   can    find  specialized   services    for  visually  handi- 
caooed  oersons. 


2021  Fourteenth   Street, N.W. 
Washington,    D.C.        20009 


97 


DISCUSSION  BY  MR.  J.  ARTHUR  JOHNSON:  This  is  a  dis- 
cussion of  the  relationshio  between  labor  union  rules  and 
employment    of  handicapoed  workers. 

MR.    JOHMSON:      I   have   a   comment,    and  then   a   question.    I 
once    did  placements   of   blind  persons   in   industry.      I  olaced 
a  blind   girl   in   a   plant   on   the    lowest    level   job.      She    did 
very,    very   well.      She    moved  uo   to  the    next    lowest    level   job; 
but   the   next    couple    of  steos    were    jobs   that   she    could  not 
handle.      There    was,    however,    one    job   three    grades   away   that 
she    could  handle,   and   I   had  to   argue    very   strongly   with  the 
union  not   to  make    an   exception    in  her   case.      I   knew  very  well 
if   they   had   done    that,    there    would  have   been   a   lot   of  dis- 
gruntled people    in  the   plant,    resulting   from  a   violation  of 
the    seniority   rule.      This    move    would  have    jumped   this   blind 
girl   over  a  substantial  number   of  persons   with    greater 
seniority,    all   of  whom  had   a   right   to   a   job   at   that    level. 
This    is    a   reverse    situation    from  what   Dr.    Feinberg  was 
talking  about. 

The   union   wanted  to   do   something   for   this    girl.      They 
thought    for  her   sake    it    would  be    good — but    finally   realized 
that    the    other  people    who   had   lost    out    would  have    resented 
her  deeply. 

The   question    I   had   relates   to   Mr.    Carroll's    comment 

about   the    man   in  the   plant   who   could  not    see    the   numbers 

on   the    machine    and   the   union    steward  fought   to  have    the 

numbers   enlarged.      I   am  wondering  if  the   unions   could  be 

educated   so    that    the    first   thing  the  steward  would   think 

of  would  be   to   have    the   man's    vision  checked   rather  than 
having  the   numbers   enlarged. 

It    is   possible    that    serious   harm   could  be    done    to   the 
individual   if  he   needed   glasses    but   didn't    get    them  because 
enlarged  numbers   enabled  him  to   see.      The    man's   eyes    could  be 
permanently   damaged. 


98 


COMMENTS  3Y  PANEL  CHAIRMAN 


Edwin  3.  Mehr* 


What    Mr.    Johnson   just    said   was    something   dear  to   my 
heart.      Somebody   in   the    community,    and   it's    very    fine    if 
it    is   the    optometrist,    should  know  the    services    available 
and  where    they   are    available,    and   to   whom  they    are   avail- 
able,   and  how  you    go  about    getting  them.      I   think   the    last 
words   were,    "you  can    find  these    services   in  any   community," 
and   I'd   like    to    correct   that,    if  I    might.      The    services   are 
available    in   almost   any   community.      I    am  not    sure    you  can 
find  them.      You  need  a   map   and   you  need  a   detective. 

I   was,  once ,  very   impressed  by   a   blinded   school    teacher, 
a   man  who   had  become    legally  blind   through   loss    of  his 
central   vision.      I   heard  him   speaking  at   a   panel   on    vocational 
rehabilitation.      He   was    recounting  his   experience.      I  was 
very   imoressed  by   this   man   because   he   had  been   rehabilitated 
as   quickly   as    anyone    I   knew  who   had   this   terrible    thinp* 
happen   to   him.      He    was   intelligent,   he   was    alert,    and  his 
wife   was   a  public   health  nurse    who   was    also   intelligent 
and   alert;    and   she   had  no   idea   what    services  were    available. 
I    repeat,    the   public   health  nurse   had  no   idea   what    services 
were    available    and   where    they   were    available    for  a  person 
who  had    lost   his    vision.      But    she   knew   a   few  places    to    start 
asking,    and  she    found  out    about   everything,    I   think,    that 
was    available    for  this    man   and   some    things    that    weren't   even 
appropriate,    but   were    available    for  people    who  had   lost 
vision . 

They   were    very   impressed  by  the    fact   that   not    one 
person   that    she   had   asked   in   agencies,  Drivate    or  public, 
gave   her  all   the    information.      There   wasn't   any    one   place 
that    she   was   able    to   get    a.ll   the    information.      Nobody   knew 
about    all   the    services,    and   if  they    did,    they  never  told 
her.      She    found   out    about   the    low  vision    clinic   at   the 
University   of  California,    Berkley,    The    School   of   Optometry. 
He    went    there    and  was   fitted   with   a   low  vision   aid. 

She    found  out    about   all    sorts    of   things,    including 
things    that    he   probably   didn't   need;    as    for  example, 
mobility  training.      He   had   very    good  peripheral   vision 


*0.D. ,    Chairman,    Committee    on    Aid   to   the   Partially-Sighted, 
California   Optometric   Association,    12^0   Scott    Boulevard, 
Santa  Clara,"  California      95050 


99 


and   so  the   mobility   training  orogram,    in   one   sense,    he    didn't 
need.      In   another  sense,    though,    it   may   have   been   very   good 
for  him.      He    said   that   gave   him  the    greatest    lift    his    spirits 
ever  had.      He    realized   there   were   a    lot    of  people    worse    off 
than   he    was.      He   could   get   around,    and  these    other  people 
had   to   use    long  canes   and   so   forth. 

I'd   like    to  emphasize   this.      If  you   do  nothing  else    for 
your   low  vision  people,    start    them  in  the    right   direction. 
You   can   do   them  a   great    service. 


100 


PANEL    4 

"Reaching  Our  Visually-Limited   People" 

Morning   Session,    March   25,    1966 

Panel   Chairman   -   DOUGLAS   P.    WISMAN,    O.D., 
Member,    Committee    on   Aid   to   the    Partially-Sighted, 
American   Optometric   Association 

****** 

PAPERS    PRESENTED   BY 

Hyman   Goldstein,      Ph.D.,    Chief,    3iometrics    Branch, 

National   Institute    of  Neurological 
Diseases    and   Blindness,    National 
Institutes    of  Health,    Public   Health 
Service,    U.S.    Department    of   Health, 
Education   and   Welfare. 

Mrs.    Kate    Kern,        President,    Maryland   State    Federation 

of  Chapters,    Council   for  Exceptional 
Children. 

Edmond  J.    Leonard, Assistant    Director   of  Information, 

President's   Committee    on   Employment 
of   the   Handicapped. 

Edwin   B.    Mehr,  O.D.  ,    Chairman,    Committee    on    Aid    to   the 

Partially-Sighted,    California   Ootometric 
Association. 

RESOURCE    PANELISTS 

J.    William  Oberman,M. D. ,    Pediatric   Consultant,    Division 

of   Health   Services,    Children's   Bureau, 
U.S.    Department    of  Health,   Education 
and  Welfare. 

Caroline    Austin,      M.A.,    Visual  Coordinator,    Public   Health 

Department,    State    of   Illinois. 


101 


SOME  .PROBLEMS    IM 
IDENTIFYING    THE    VISUALLY    LIMITED 


Hyman   Goldstein* 

The    word   "identifying"    in   the   title    of   this   paper  is 
used,   not    in    a   diagnostic   sense,    but    rather  with   respect    to 
ways   and   means    of   determining  the   magnitude    of   the   numbers    of 
visually    limited  persons. 

My  experience    in  identifying  visually   handicaoped 
groups   in  terms   of  their   characteristics    has   been   largely 
limited   to  the    most    severely    disabled,    namely,    the    legally 
blind.      However,    it    is    my    belief   that    while    there   are    dif- 
ferences   in  the   tyoes   of  oroblems   encountered   in   studies    of 
the    magnitude    or  prevalence    of   blindness    compared   with   those 
of  other   visually  handicapping  conditions,    there    are   many 
similarities    in  the   aooroach   to   such   studies.      Surely   what 
has    been   learned   from  studies    of   the    one   may,    in  oart,    be 
aoolied   to  the    other.      This    is    so   because,    except    for   the 
arbitrary    line    of   demarcation   used   to   define    legal   blindness, 
namely,    visual   acuity   of  20/200,    there    is   no   significant 
difference    that    distinguishes   the    characteristics    of 
those   persons   with   visual  acuity   slightly   better  than   20/200 
from  those   with  visual   acuity   slightly  worse   than    it. 
Similar  reasoning  would   apply   to   any  arbitrary    line    of  de- 
marcation. 

In   my   comments   which    follow,    I    shall    refer  to    two 
terms   which   are    often   confused  and,    hence,    should  be    defined 
at    the    outset.      These    are   prevalence    and   incidence.      "Prevalence** 
is    defined   as    the   number   of  cases   with   a   specified   disease    or 
impairment    living:  in   a   community   at    a  given   time;    "incidence*  as 
the   number   of  new   cases   with    such    disease   or  impairment    occurring 
in   the    community    during  a   given   period  of  time.      Before    anv 
oroblem  dealing  with   a   disease    or  imoairment    can   be   effectively 
tackled,    one   needs    reliable    information    on    its   incidence    and 
prevalence    in   the   oooulation   as   well   as   on   the   causes    of  the 
disease    or  impairment    and   characteristics    of  the    affected. 

There    are    two  well-established  ways   of   getting   information 
on   the   prevalence    of   disease    or  impairment    in    a   community: 
(1)    the    sample    survey    (including   the    census   which    is    100   per- 
cent   sample    survey),    and    (2)    a   routine    reporting  system  resulting 


*Ph.D. ,    Chief,    Biometrics   Branch,    National   Institute    of  Neuro- 
logical  Diseases   and  Blindness,    National   Institutes   of   Health, 
Public   Health   Service,    United   States    Department   of  Health, 
Education   and   Welfare. 


102 


in   a  register.      Each  has   its   advantages  and  disadvantages.      In 
both   there    is   confidentiality   of  the    identity   of   interview 
coupled  with   some    objective   examination. 

(1)      In   the    first   instance,    an   attempt    is   made   to   inter- 
view  a  random  sample    of  households   and  to  obtain   certain 
Information   about    the   prevalence    of  the    condition   being   surveyed. 
This   condition   is    often  poorly   defined  by  the    interviewer  and/or 
poorly   understood  by  the   respondent.      Questions    relating  to 
impairment    cannot   be   answered   definitively   in   the    absence   of 
examination.      The    institutionalized  are   usually   missed.      Too 
often   the   person   answering  the    door  is    asked   to   report   on   the 
condition    for  every   member  of  the   household.      Also,    too   often 
this   person   may  not  even  know  of  the   existence    of   such   condition 
or,    if  he   knows,   may   be    reluctant  to   reveal   it   to  a   stranger. 
In   very   few  surveys   is   a   determined  attempt   made,    through  re- 
peated call-backs,    to  see   every   person   in   the   household. 

It   is   evident   that   the   addition   of  objective  examination 
to   the   interview  would   greatly   increase   the   validity   of  data 
secured  by   sample   survey.      Unfortunately,    however,    the   number 
of  sample    surveys   where   an   attempt    is    made   to   obtain   data  by 
objective   examination   on  every  person,   including  the   young, 
the    aged,    and  the   infirm,    in  homes    of   a   randomly   selected 
group   of  households,   may   be   counted   on  the    fingers    of  one 
hand. 

One   such   study,   however,    is   at   present   under  way   in 
Egypt,    sponsored  and   financed  by  the   National   Institutes   of 
Health  under  a   P.L.    480   agreement   with  the   University   of 
Alexandria,   Egypt.      In   this    study,   a   four  percent    random 
sample    of  households   was   drawn   from  a  population   of  25,000 
such  households   in  an   area  in  Alexandria  cutting  across 
strata   of  all   socio-economic    levels.      A   similar  sampling 
was   made    in   rural   areas   outside    of  Alexandria.      An   attempt 
is   made    to  examine    the   eyes    of  every  member   of  the   household, 
using  the   Titmus   Optical  Vision   Screener  and  Schweigger 
Portable    Perimeter.      Where    distance    vision   is   20/200   or 
worse   with   the    better  eye,    refraction   is   done    to   determine 
whether   such   vision   may  be    corrected  to  better  than   20/200. 
Where    such  vision    is   better  than   20/200,    the    field   of   vision 
is  measured. 

Persons,    screened  out   on   the   basis    of  decreased  visual 
acuity  and/or  visual   field    (20   degrees    or  worse)    as   potentially 
blind,    are   examined  by  an   aphthalmologist   to   confirm  the   visual 
acuity   and   field   vision    findings   as   well   as  to  attempt   to 
arrive   at   a   diagnosis   which   is    classified   in   a   uniform  way  by 
site   and  etiology.      Of  course,    such  a   sample    survey   furnishes 
us   with   visual   acuity   data   on   a  sizeable    segment    of  the   non- 
blind  population  as   well  as    on   those  with  monocular  or  binocular 
blindness. 


103 


Such    a   survey   has   enabled  us    to   secure    age-sex   blindness 
orevalence    rates    in   the    study  area   with   which    to   compare 
rates    on  the   basis    of   a   future    voluntary   registration   of  the 
blind   in   those   areas.      While    surveys   which   include    objective 
visual   measurements   oroduce    more    meaningful   data   than   those 
limited   to   interview   alone,    the   high   cost    of   conducting   ob- 
jective  examinations   is    generally   an   insurmountable   barrier. 
Indeed,    the    financial   obstacle   undoubtedly  accounts    for  the 
very    limited  number   of  surveys   which    include   examination   wi-th 
optimum   correction. 

Thus,   the    sample    survey   is    a   one-shot    attempt   to  estimate 
the   prevalence    of  a   condition    in  a    community   at    a   given   time. 
Incidence    of  a   condition   is   not    available   by   this    method  un- 
less   attempts   are    made    to   re-survey   the    identical   sample    after 
a   suitable    interval   of  time    in   order   to   determine    the   cases 
newly-developed   in   the    interval  between   surveys.      A   sample 
survey   is   not    usually   tied  to   any    further  follow-up   of  the 
cases    revealed  by   the    screening   for  purposes   of   confirmation, 
diagnosis,    or  treatment.      In   view   of  the    fact  that    It    generally 
applies   to   only   a   sample    of  households    and  not    to   the    whole 
community,    it    obviously    cannot   identify   all    individuals    in   the 
community  who   are    in  need   of  specific    services. 

(2)      The    register   derived   from  a  continuous    reporting 
system  is    a   continuing  mechanism  from  which   data   may   be 
secured   on  prevalence    and   incidence.      It    is    in  the    great 
majority   of   cases   based   on   authenticated  professional  exam- 
ination and   diagnosis.      It   presents   a   continuing   contact 
with  the    registrant    so   that   services,    treatment    and   changes 
of   status    may   be    documented  and   so    that   updating   of  the    data 
by    removal   of   deaths,    sight    recoveries,    and   so    forth,    may 
bring  the    register  up   to   date. 

A   register  may   understate    the   prevalence    of   affected 
population   because    of   one    of  two   basic    reasons: 

(a)  A   person   may  not   have   been   diagnosed  by    a  professional 
examiner; 

(b )  A   person    so    diagnosed  may  not  have   been   reported  to 
the    register  by   the   examiner. 

The    under- reporting  due    to  the    first    reason   is   presumed 
to  be   minimal   in   "the    case    of  blindness   because    of  the   nature 
of  the    condition.      That   due   to   the    second   reason  may    vary  with 
socio-economic    status,    age    or   other   factors.      However,    it 
should  be   mentioned  that   even   the   wealthy  blind  need   and 
want    such    services   as    talking  books.      Their  contact    with   agencies 
providing  such    services   would  make   them  known   to   the    register. 


104 


This   would   fulfill  the    latter' s   needs    as  well   as   that    for  more 
complete    statistics.      Optimally,    in   this    type    of   operation, 
periodic  evaluation   of  the   error   of  under- reporting  is   by 
house-to-house    surveys   with    some   type    of   objective    screening 
examination   supplemented  by  professional  examination   of   all 
or  a   sub-sample    of  those    screened  through   as   potentially 
affected  with   the    disease    or  impairment    under  study.      Or 
else,   it   may   be    feasible    to    get    the   cooperation   of  a  sample 
of   the   professional   community   to  permit   comparison   of  the 
data   in  their   records    of   the   blind  with   those    on   the    register. 
This   would  permit    a   determination    of  the   under- re  porting  of 
diagnosed  blindness   to   the    register. 

Society   has    traditionally,   through   governmental   sources, 
made   available    specific   types   of  services    to   the   blind.      Thus, 
it    is    automatically   guaranteed,    when   a   blindness    register  has 
been  established,    that   statistics   on   the    identity,    character- 
istics   and  needs   of  such   blind  persons   would  be    generated.      A 
case    register  is    one    record   system  which   readily    lends    itself 
to  dual  use,    as    an   administrative   tool   in   a   service   program, 
and  as    a  source    of  morbidity   data.        Such   statistics   are   a 
great   help   not    only   to   the    administrator  but    also   to  the 
research   worker  interested   in   various   studies    relating  to 
specific   types   of  blinding  conditions. 

Thus,    the    register   offers   a   mechanism  of   generating 
statistics    on  prevalence   and   incidence    of  the    condition   under 
consideration    on   a   continuing  basis.      Through   continuing   contact 
with  the   patient,    where    desirable,    it    can   keep    an   accounting 
of  services   and  treatment    rendered  and   can  provide    statistical 
data  to   show   the   effect   over  time    of  the    introduction   of  pre- 
vention  and   control  measures.      It   offers    access    to    study   of 
specific  types    of   research  problems. 

Several   years   ago   in   response   to  a    flood   of   inquiries 
to  the    Biometrics   Branch,   NINDB,    for   soecific    information  on 
the   prevalence   and   incidence    of  blindness    by    age,    sex,    race, 
and  cause    of  blindness,    an  effort   was    undertakne    to   set    up 
a  system  in  this    country  which   might   make    it   possible   to 
collect   blindness    data  uniformly   on   a   routine,    continuing 
basis,    using   a  standardized   definition    of  blindness    and 
classification   of  causes    of  severe    vision   impairment   and 
blindness.      Such   data   would  make    it  possible   to  arrive   at 
annual   age-sex-race   prevalence   and   incidence    rates   by 
cause,    visual   acuity   and   other  characteristics    of  the   blind. 
This    develoDment,    the    Model   Reporting  Area   for  Blindness 
Statistics  ,2»  3    sponsored  by   the   National   Institute    of 
Neurological  Diseases    and  Blindness    (MINDB),   now  includes    14 
states,    with   4    more   states   to   be   admitted   soon.      When  this 
occurs,   it   will  embrace   about    one-third   of  the   United   States 

105 


population.      It   is   hoped  that   before    too  long  the    composition 
and  number  of  states   in   the   area  will  be    such  as   to  permit 
national  projections    of  statistics   on   blindness. 

The   Model   Reporting  Area  makes   use    of  the    mechanism 
that   many  states   have    already  established,    namely,    a  blind- 
ness   register.      Such   register  may   be   established  by   state 
law  or  be    on   a  voluntary  basis.      Reporting  to  the    register 
may   be    mandatory   or  voluntary.      At    any   rate,   what   the    Model 
Reporting  Area  has    done    is   to  ensure,    as    much   as   possible, 
that    certain   standards,    alluded  to  above,    are    met    so  that    the 
data   made   available    to  the  NINDB,    are   poolable   and   comparable, 

Now  what    does    all   this   have    to   do  with   the   partially 
sighted   who   are   not;  legally   blind?      Obviously,    although  a 
number  of  states    offer  services   to   such   persons,    very    few, 
if  any,   keep   statistics    on   such  patients  which   admittedly 
represent   only   a   fraction   of  those   with   moderately   defective 
vision.      If  we    recognize   that    defective   vision   is    a  public 
health   problem,    if  only   by   its    sheer  magnitude,    then  the 
possibility   of   an   approach   to   secure   uniform   statistics 
become    apparent. 

In   view  of   the    fact   that    a   large   percentage    of  all 
sensory   input    is    visual,    a  defect   in  this    sense    organ   must 
be    considered   seriously,   particularly   in   light   of  its 
relationship   to   the    individual's    capacity  to   respond   and 
grow  educationally,    occupationally ,    recreationally    and 
socially.      The   extent    to  which   impaired  vision   impedes    light 
stimuli    from  reaching  the   brain  and  the   extent    to  which   best 
correction   or   other  necessary   treatment   removes    this    impedi- 
ment   directly   determines   such   ability   of  the    individual   to 
respond  and   grow.      For  instance,    a   central   visual  acuity   of 
20/50   in   the   better  eye   means    a   loss   of  25   percent   of  normal 
central   vision.      A   similar  acuity,    20/160 — not    considered 
legally   blind — oermits    the    individual   only    30   percent   of 
normal   central   vision.      Thus,    it   would   seem  that    statistics 
are    urgently  needed   to    determine   the   percentage    of   central 
vision  possessed  by    our  non-legally  blind  pooulation   and   its 
relationship   to  ability   to   adjust   to    live    situations. 

An   undertaking   to   obtain   such   data   is    difficult   due   to 
a  number  of   reasons.      Defective    vision   is    fairly    common. 
Many  people    fail   to    realize    that    their  uncorrected   vision 
is   not   normal,    or  if  corrected,    that   their   correction  needs 
periodic   adjustment.      Many   oeople,   particularly   those   with- 
out  best   correction,    make    some    adjustment   to   it.      They   may 
learn    to  live   with   their  disability,   not   realizing  the   extent 
to   which   their  potential    for  more   effective    living  and   learn- 
ing has    been   impaired. 

106 


A   recent   National    Health   Examination   Survey^    of   6,672 
persons    among  the   adult,    civilian,    non-institutionalized   U.S. 
population,    aged  18-79   years,   measured  binocular  visual   acuity 
for  distance.      On   the   basis   of  this    survey,   projections    to  the 
United  States   population   were    made   and   it   was   estimated  that, 
in   this    age    group,    some    40   oercent   were   partially   sighted   with 
uncorrected  visual   acuity   between  20/30    and   20/100   inclusive, 
which   the   present   oaoer  defines   as    decreased   distance    vision. 
Under  usual   correction,    the   proportion   drooped   to   approximately 
26   percent. 

Although  near   vision    is   not   a  part   of  the    definition    of 
blindness,    it    is,    of   course,    of   great   importance    in   our  daily 
lives.      In   the    survey   .just  mentioned,      near  vision   examinations 
were    also   made    of   the    same    group.      The    results,   projected   to 
the    country   as   a   whole,    indicated   that,    for  uncorrected   near 
vision,    some    39   percent  had   acuity    levels   between    14/20    and 
14/70    inclusive,    defined   in  the   present   paper   as   decreased 
near  vision.      Under  visual   correction,    this    dropoed  to   about 
34   percent.      In   view  of  the    fact   that   "usual"    and  not    "best" 
correction   was   measured,   percentages   quoted  are   probably 
maximum   figures.      This    would   indicate    that,    apart    from  the 
legally   blind,    up   to   one-quarter   of   the    adult   population   do 
not   enjoy   20/20    distance    vision  with   correction.      For  near 
vision,    this   proportion    may   be    up   to   one-third   of  the   population. 
The   National   Health   Survey,   as    indicated  above,   was    based  on 
an  examination    of   adults   only.      The    sample   examined  is,   of 
course,    small   and  the   projection    to   the   population    of   adults 
for  the    whole    country   makes   it    subject    to   somewhat    large 
sampling  errors. 

What   is   needed   is   a   small  number  of  pilot    demonstration 
projects,   uniformly  planned  and   conducted,    throughout   the 
country.      The    cooperation   of   the    local  opthalmological, 
optometric,    and  medical   societies   should  be   enlisted   to 
support    the   projects,    as   well   as   that    of   individual  examiners 
to   report   their    findings   to   a   central   register.      Through 
adequate    and   continuing  publicity   and  the    offer   of   free 
examinations   and   services,    the   public   of   all   ages   should  be 
invited   to  have   their  vision  examined  so   that    statistics    on 
the   distribution   of   distance    and  near  vision   and   of  needed 
services   might   be    obtained    for  the   whole    community.      Whether 
a  partially   sighted  person   wants    services   should  have   no 
bearing  on   his    inclusion   in  the    register   of   such   Dersons. 
Service    records    alone    cannot   ordinarily  be   used  as   a   source 
of   information    concerning  the.,  magnitude    and  nature    of   disease 
or  impairment    in   a   community.         Confidentiality   must,    of 
course,    be   pledged. 

107 


Data   secured  from  such   a  project   would   give   us   some 
Indication  of  the   extent   to  which   all  prevalence    rates    for 
individuals  with   different    degrees    of   visual  acuity   vary   with 
age.      Prom  data  reported  there    appears   evidence   that   the 
prevalence    rate    of  defective   visual   acuity   increases  with 
increasing  age.      As   has   been  noted  by   many,   an   increase    in 
rates  with   age    is   true    for  the    legally  blind    (20/200,    or 
worse) . 

Such  a  voluntary   registration  as   has   been   indicated  is 
now  under  way  in  the   Egyptian  project  mentioned  above.      Pro- 
jects  as  these,   if   the   population   cooperated  whole-heartedly, 
would  provide    data   by  age,    sex,    race   and   other   characteristics 
helpful   in   determining  the   population    groups    most    at    risk   of 
developing  visual   deficiency.      They  would,    no  doubt,    help   to 
pick  up   incipient   eye  pathology   for  referral   for  opthalmological 
care   and  possibly   lead  to  prevention  and  control   of  certain 
blinding  disorders. 

A  recent    Gallup  poll   for  Research  to  Prevent   Blindness, 
Inc.    estimated   that    some   three    and  one-half  million  people 
are   affected  with   "serious"   eye   problems."      As   a  matter  of 
fact,    the   estimate    indicated   that    almost  one    out   of  every 
ten  households   in  this    country   has    a  member  with   a   "serious" 
eye   problem.      It    is    obvious   that    the   way   to  prevent   eye 
problems    from  becoming   serious   is    through  prevention   and  early 
treatment   of  eye   disease. 

The    determination   as    to   whether   registers    of  the   visually 
limited  are   worthwhile   and  feasible    can  be   made   after  some 
experience    with   the   problems    involved   in   the    operation  and 
maintenance   of   the   demonstration   registers   and  with   the   value 
of  the    data  produced   over  a  period   of  time. 


Bethesda,   Maryland     20014 


10  8 


REFERENCES 


1.  Cutler,   Sidney   J.  ,    "The    role    of  morbidity   report- 
ing and   case    registers    in   cancer  control." 
Public   Health   Reports.    65:      1084-1089,    1950. 

2.  Goldstein,    Hyman   and  Goldberg,   Irving  D. , 

"The   Model    Reporting  Area   for  Blindness    Statistics," 
Sight-Saving  Review,    32:      84-91,    Summer,    1962. 

3.  Goldstein,    Hyman,    The   need   for  uniform  statistics 
on   blindness,   J.    Am.    ODtometric   Association, 

34:      1388-1392,    19^3. 

4.  National   Center   for  Health   Statistics.      Binocular 
visual   acuity   of  adults,   United  States,    1960-62, 
Vital,  and  Health   Statistics.   PHS   Pub.    No.    1000, 
Series   11   -  No.    3^      Public   Health   Service, 
Washington,    D.C.,    June    1964. 

5.  Weymouth,    Frank   W. ,    "Effect    of  age    on   visual   acuity." 
Vision  o_f  the   Aging  Patie_nt:    Am.    Optometric  .Symposium, 
Edited'  by   Monroe   J.    Hirsch   and   Ralph  E.    Wick. 
Chilton   Co.,    Philadelphia,    Pa.,    I960. 

6.  Highlights   of  Public   Opinion    Survey   Conducted   for 
Research   to    Prevent   Blindness,   Inc.      The    Ophthalmologist, 
Jan.    -  Feb.    1966. 


109 


THE  COUNCIL  FOR  EXCEPTIONAL  CHILDREN 


Mrs.  Kate  C.  Kern* 


I    come    as   spokesman   from  Maryland    for  the   Council    for 
Exceptional    Children.      Another   confession   I   have    to   make    is 
that    I   am  a  psychologist    in   a   school   system  of   110,000 
children.      I    suffer  through   some    of   the    same   polite    con- 
fusion that   optometrists   and   ophthamologists   endure. 

What   is    this    CEC   organization?      Perhaps    it   is    as  new   to 
you   as   specific   aspects   of  your  discipline   are    to   me    and 
without    some   background  you  could  not   be    aware    of  the    signi- 
ficant   role   CEC   is  playing  in  reaching  children   and  adults 
with    limited   vision. 

The   Council   for  Exceptional  Children   is    first   of  all 
a  professional   organization   with   a   membership    representing 
all   disciplines    but   made    up    largely   of  special  education 
teachers.      In   addition,    there    are    speech,   physical   and 
occupational   therapists,   physicians,    nurses,   osychologists , 
school  administrators,    reading  diagnosticians,    social   workers 
and   teachers    of  blind   and   visually    limited  children.      In   some 
instances   parents    are   members   but    in  most    states   CEC   is 
strictly   a  professional   organization,    unique    in  nature    and 
goals. 

CEC   is    constantly  engaged   in   seeking   more   effective    ways 
to  promote   the   education    of  all  exceptional   children,    both 
gifted   and  handicapped.      Active    cooperation   with   oublic   and 
private    agencies    and   organizations   interested   in   the   education 
of  exceptional   children    is   a  constant   CEC   method   of   operation. 

The   official   journal    of  the    Council   is   called  Exceptional 
Children.      It    is   published  9   times    a  year.      National   member- 
shop   up    to   date   totals   23,300   members    representing  all   states, 
Canada  and   some    foreign   countries.      There    are    412    chapters,    3d 
state    federations    and   7   branches.      Annual  membership    fee    varies 
from   $8.50    to   $12.50    depending   on   the    state,   with    student 
membership   being  $4.25.      All   memberships    include   the    Journal. 
International,    regional   and   special   conventions    are    important 
parts   of  CEC's   professional  program.      This    year   our   inter- 
national   convention   will   be    in   Toronto,    Canada   in   Aoril. 


*President,    Maryland  State    Federation   of  Chaoters,    Council 
for  Exceotional   Children 


110 


Now  you  may  well  ask — why   all  this    background  advertise- 
ment  for  CEC?     How  could  such   an   organization  affect   you? 

There   is   at    least   one    division    of  CEC   which   will   in- 
trigue   you.      Of   the    3    divisions   within  CEC,    one    is   called 
CEPS — The   Council    for  the   Education   of  the    Partially  Seeing. 
Membership   costs   $1.00    for  CEC   members   and  this    includes   a 
Newsletter.      Their  statement    of  purposes   is   1)    to  bring  about 
a  better  understanding   of  educational   and  emotional   problems 
which   may  be   associated  with  partially   seeing  children,    2)    to 
encourage    the    study   of  new   ideas,   practices   and  techniques   and 
to  disseminate    this    information   among  members   of   the    group, 
and   3)    to  promote   a  closer  social  and  professional   relationship 
among  teachers   of  the   partially   seeing. 

It   would   seem  to  me   that   optometrists   could  well  be 
specifically   involved   in  this   second  purpose,    that   of  encourag- 
ing the    study   of   "new   ideas,   practices   and  techniques"   not 
only   in,    for  example,    pre-school   vision   screening  at   the   annual 
round-up   prior  to   kindergarten   placement    in   the    fall   but    also 
as  possible   consultants  to  parents   and   teachers,    working  part 
of  the    team  rather  than    in   isolation,    to    further  the   educational 
development   of  partially   seeing  children. 

Incidentally,   before    I   finish,    the   conglomeration   of  terms 
related  to   those    individuals   with   vision   problems   other  than 
blindness   may   well   get   the   best    of   me.      Loss   of   visual   skills, 
subnormal  vision,    partially  sighted,    visually   limited,   visually 
handicapped — whether  we   accent    the   positive   or  not,    it   would 
be  beneficial   to   lay   and  professional  people    if   one   term 
could  be   utilized.      Right   now,    in  our  county,    "visually- 
limited"   is   "in"   while    "partially   seeing"    is   "out".      There 
seems   to   be  no   doubt   but   that    the    right    label   or  combination 
of   letters   can   mean   the    difference   between  parental  acceptance 
or   rejection   of  a   child's   special  placement  and/or  the   need 
for   individualized  teaching  aids    or   resource    rooms. 

This   brings   me    to   the   point    of   emphasizing  that    you, 
as   vision   consultants,   need  to   be   aware    of  terminology  employed 
by  your   local   private   and  public   school   systems:      We   don't   talk 
a  different    language   but    frequently   translations   are   in   order! 
The   kids   don't    differ   but   the    label   does   and  we  haven't    gotten 
away   from  labeling  yet.      Even   being  "normal"   poses   questions 
and   concerns.      You  may   get   more   attention    if  you're  not! 

This   brings   me   to  ask  this    question — quite   unrelated — 
how  many   of  you  have   ever   visited   the    classroom  or  spoken   to 
the   teacher  and/or  itinerant    instructor  of   one   of   your   young 
patients?      How  many   of  you  have    observed  the   Snellen   screening 


111 


done   by   volunteers    in  the    schools?      How  many   of   you  have 
observed  a  classroom  teacher  as  well  as   an    itinerant   teacher 
working  with  one   of  your  visually   limited  patients?     How  many 
of  you  have    appeared   on   PTA,    CEC    or  community   Danels   where 
vision   was   one   of  the   concerns   as   related   to  reading?     How 
can   you  "reach"    visually   limited  people    if  you  don't   observe 
them  outside    your   office? 

The   emphasis   today   in   all   related   disciplines   is   on   the 
"whole   child".      This   concept    includes    the   child's   reaction 
to   the    total   educational  process   since   he    spends    6   hours   a 
day,    5   days   a   week,    9   months   of  the   year   in   school.      Asking 
"Mommie"   how  Junior   is    doing  in   school    is   hardly   revealing   or 
accurate. 

Now  about   this   Snellen  Chart   which   I    learned  yesterday 
was   born   after   the   Civil  War,   not    before.      In  a   way,    this 
is   rather  an    insidious   device    for  trapping  teachers   and  parents 
into  believing  a  child's   vision    is    o.k.    or  "he  needs   glasses". 
The   chart    itself   is   not    to   blame    although   it    is    old  enough  to 
be    retired--but   rather  the   handling  of  the    findings   which  are 
frequently   checked  off   on   a  vision   and  hearing  form  as   "negative"- 
whatever  that    means.      If   you   find   me    somewhat   alarmed  by  the 
popular   use    of   the    Snellen   chart — it    is   with   reason. 

In   the    last    10   years   I   have   been   involved   in  numerous 
conferences   with  both  parents    (I   emphasize   the    "both"    for 
reasons   other  than   that   it   still   takes   two)    which  have   centered 
around  children  with   learning  problems    serious   enough  to   re- 
quire   the    services    of  a   psychologist.      With  rare   exceptions, 
regardless    of  whether  the    child   is   6    or  16,    rich   or  poor, 
bright   or  retarded,    he — and   it   usually   is   a  boy — has  not   had 
a   visual  examination. 

In   fact,    parents  are    surprised  when  I   recommend   such 
a  procedure,    saying  that    I   believe   every   child   should  have 
a  visual  examination   by   the   age    of   6,    when  he   is    learning  to 
read — I'm  not   saying  "ready"--in   order  to   rule    out   any   correct- 
able   visual   defect.      You   see,    their  child  has   already   had  an 
eye   test    "In   school"   and   "there   is   nothing  wrong  with  his    eyes." 

Or  the    opposite   may   occur  as   it   did  the    other  day.      I 
made   a  home    visit    in  the   country   to  a   deprived   family  where 
the    father  is   chronically   ill  and   the   mother   is    struggling 
to  care    for  6   children,    4   of  whom  are    already  in   classes   for 
the   mentally   retarded.      She    said   she   had  .just   received  a 
long  form  to   be    filled  out    in   detail   so  her  8   year   old 
daughter  could   go  to  the   Health   Department  Eye   Clinic.      She 
was   more    frightened   of   this   complicated   form  and  the    glasses 
she    was    sure    would   follow  than    she   was   of  the    condition   of 
her   ill  husband   for  whom  a   Medicare    card  was   needed.      This 


112 


mother   is  not    retarded,    but   the    manner   of  handling  this    re- 
ferral  suggests   that   the   whole    system  of  reporting  possible 
health  problems   to  parents   is   sometimes   being  handled  by 
robots   rather  than   people—and   I   don't   mean   the   public 
health  nurses,    who   do  a  back-breaking  job. 

In   our   metropolitan   area   we   would  have    less    trouble 
persuading  people   to  accept   health   services    if  there    were 
more   thought    given   to  presenting  what   we   want   people   to 
accept.      Incidentally,   when   parents    ask   for  the   name    of 
an   eye    doctor   or   any   other  kind   of   doctor,    we  are    required 
to   give    at    least   three   names.      I  name   both   ophthamologists 
and    optometrists. 

While    I   have    this    rare    opportunity,    I   would   like    to 
share   with   you   another   concern  with   which   you  may   or  may  not 
be   familiar  and   that   is   the   problems    of  the   visually-limited, 
mentally   retarded   child   and/or  the   physically   and  mentally 
handicapped   or  multi-handicapped   child  with   a   serious    but  not 
severe    vision   problem  (i.e.,   not    blindness). 

First   of  all,    the   mentally   retarded  child  with  defective 
vision — there's    a  term  I   missed  earlier — is    likely   to  be 
wearing  a  halo   supplied  by  his   parents.      The    vision  problem 
is   accepted,    sight-saving  material   is  welcomed.      The   primary 
problem,    as   the   parents   see    it,    is    that   their  child  can't   see 
very   well.      With   visual   aids   he,    they   believe,    will    soon   be 
close   to  grade    level. 

We   see   a   parallel   with  parents  who   have   a   child  with   a 
severe    language    disorder  or  autistic   behavior.      As   soon   as 
he    learns  to   "talk,"   he'll  be   o.k.      Or  again,    if  there    is    a 
vision   problem  accompanied  by  emotional   disturbance,    the 
former   is   accepted  and  discussed  but   not   the    latter.      As 
you  know,   handicaps    cannot   be    so  neatly   separated   out   nor 
can  they  be   treated   in   isolation. 

Teachers   are   aware    of   the    multiple   problems   more   than 
parents   and   sometimes   more    than    family   physicians   who   may   be 
loathe   to   communicate   what    they   suspect   but   prefer   selecting 
out   what    is  palatable    to  the   parents.      If  we   deal   with   false 
concepts,   we   will  eventually   be   confronted  with  angry,   hostile 
parents   who   will   blame    us.      The    child   is    the    innocent   victim. 

In   one    of  our  counties   our   itinerant   teachers    for   visually 
limited   children   have   been   being   reluctant   to  provide    instruction 
and/or   visual  aids    to   mentally    retarded  visually-limited  children. 
The    reason    given   has   been   that   they    have   not    been   trained  to 
instruct   the   mentally   retarded.      Undoubtedly,    this    is   a   legitimate 
reason   but   kind   of   tough   on   the   kids.      Don't   all   children  have 
equal  but  not   necessarily   identical  educational  needs? 

113 


In  conclusion,  it  would  seem  to  me  that  better  communi- 
cation with  agencies,  organizations  and  school  systems 
followed  by  a  steady  building  uo  of  community  relations  is 
needed  to  reach,  to  make  aware  of  eligibility  and  to  get 
acceptance  of  the  services  available  for  the  visually 
limited  from  ootometrists. 

Mrs.  Joyce  Bromley  of  Knoxville,  Tenn.  is  oresident  of 
the  Council  Division  for  the  Education  of  the  Partially  Seeing 
(CSPS).   In  corresponding  with  me  concerning  this  paoer,  she 
wrote,  "Your  inquiry  oinpoints  a  need  for  additional  inform- 
ation in  techniques  of  publicizing  the  services  available  for 
visually  handicapped  people.   In  the  past  we  have  relied  upon 
the  National  Society  "for  the  Prevention  of  Blindness  and  the 
American  Foundation  for  the  Blind  for  their  suggestions" .   So 
the  very  fact  that  I  was  invited  to  speak  before  this  Association 
as  a  member  of  CSC  has  already  paid  dividends.   I  would  like  to 
suggest  that  you  submit  articles  to  Exceptional  Children  clarify- 
ing your  role,  especially  as  it  re  1  at  e  s  tot  he  ~e  d~u  cation  a  1 
Drocess  as  well  as  to  vocational  rehabilitation. 

I  would  also  encourage  you  to  present  papers,  and  attend 
our  national  and/or  regional  conventions.   You  need  to  be  seen 
as  well  as  heard!   Your  fresh  approach  may  well  inspire  teachers 
to  look  at  the  visually  limited  child  with  new  insight. 


6709  Pyle  Road 

Bethesda,  Maryland   20034 


114 


QUESTION  DIRECTED  TO  MRS.  KERN:   In  what  ways  can 
optometrists  assist  in  working  with  exceptional  children? 

MRS.  KERN:   Since  all  we  have  time  for  is  a  capsule  answer, 
I  would  say  that  optometrists  (and  by  that  I  presume  I  mean  the 
American  Optometric  Association)  should  move  toward  exceptional 
children  being  required  to  have  a  visual  examination  prior  to 
their  admittance  to  special  classes. 

While  I  have  to  speak  about  Montgomery  County  (Maryland), 
as  this  is  the  system  with  which  I  am  associated,  I  suspect 
that  our  situation  is  not  at  all  atypical.   For  special 
education  placement  we  require  a  "physical"  examination, 
administered  either  through  the  school  physician  or  a  private 
physician,  as  well  as  an  individual  psychological  examination. 
However,  we  do  not  require  a  visual  examination  at  all,  unless 
the  child  manifests  a  visual  handicap.   I  think  this  is  one 
direction  in  which  optometrists  might  seek  extension  of 
current  health  services. 

Actually  I  think  that  a  visual  examination  should  be 
required  of  every  school  child,  but  maybe  it  would  be  politically 
expedient  to  try  to  start  with  the  relatively  smaller  group  of 
exceptional  children. 

Second,  I  would  say  that  if  you  are  going  to  deal  with 
exceptional  children,  you  must  know  the  people  who  work  with 
these  children.   Don't  stay  in  your  office!   Get  out  and  come 
to  meetings  where  there  will  be  the  professional  people  who 
are  working  with  exceptional  students.   They  will  then  learn 
to  know  you  and  your  interest  in  these  children.   Also,  you 
will  learn  to  know  them  and  to  appreciate  some  of  their 
problems ! 


115 


COMMUNICATIONS    IN    REACHING 
THE    VISUALLY-LIMITED   WORKER 


Edmond  J.    Leonard* 


Speaking  on   behalf   of   the    President's    Committee,    I 
would   like   to    first   say   a  word  of  appreciation    to  the   sponsors 
of   this    conference    for  the   immensely   important    contribution 
they    are   making  by   focusing  professional   attention    on,    among 
other  things,    the    vocational   problems    and   solutions    of 
visually   handicapped  persons.      Defective    vision,   particularly 
when    it    goes    unrecognized,    can    result    in   unemployment,    but 
more    often,    in   underemployment. 

In   seeking  out    those   who   stand  to  benefit   by  the 
services   of   optometrists,    you   are    benefiting  not    only   the 
visually-limited   individuals,    but    through   their  greater 
potential   for  participation    in   their  communities,    you  are 
helping  them  to   be   more   productive,    useful,    and   viable    members 
of  society. 

The   President's    Committee,    as   you  may  know,    is    a  vast 
network    of   organizations   and   individuals    charged  with   making 
a   deep   social   and  economic    impact    on   the   employers    of   this 
nation   by   generating  among  them  a   favorable   attitude    toward 
handicapped  workers.      The    Committee   attempts   to    create   a 
climate    of  acceptance    for  handicapped  persons   generally   but 
in  particular,    its   primary   educational   and   informational 
efforts    are    aimed   at  employers. 

I    mention   this    because   it  has    relevance    to  the    subject 
of   this    panel:      How   do   you   reach   the    specific    e;rouo   of  visually- 
limited  people    who   can   benefit   by  what   you  have    to   offer? 

This    calls    for   analyzing  that    segment    of   the   population 
with  which   you   are    trying  to    communicate.      Basic   to   carrying 
out    your  program  Is    the    comoilation   of  a   list    of  the   people 
you   want   to   reach.      For  instance,    the    President's    Committee 
wants   to    reach   employers   with    its   message,    but   we    find  that 
there    are    many   sub-groups,    all   of  whom  are    valuable    recipients 
of,    or  in   a  position   to   transmit,    our  message.      There    are 
personnel   managers,    foremen,    shop   stewards,   supervisors,    middle 
management   peoole,    executives    of   large    industries,    and   small 
enterpreneurs ,   manufacturers'    associations,    chambers    of  commerce, 
organized   labor — all   of  whom   can    further  the   hire-the-handicapped 
program. 

*Assistant   Director   of  Information,    The    President's    Committee 
on  Employment    of  the    Handicapoed. 


116 


Each   is    a  separate   entity,    and  each   group   must   be    dealt 
with   separately.      They  are  not   tuned   into   a   common   channel 
of  communication,    so    it   becomes   necessary   to   address   each 
one    separately. 

An   analysis   of  the    sub-groups    you  are   trying   to    reach 
may   amaze    you.      Do  you  want   to  contact   the    teachers   of   school 
children,    or  children    in   special  education   classes?      Should 
you  try  to   get    your  message    across   to  clergymen,    counselors, 
medical   and  paramedical  people,    visiting  nurses,    social   service 
workers?      Think   of   the    many  resource   persons   who   can   act    for 
you   in   reaching  these    visually-limited  people,    and   it   becomes 
obvious   they   do  not    speak   a   common    language.      It   is    just   as 
apparent    that   you  must    deal   with   them   separately. 

A   second   basic   question   you   must   answer   for  yourselves 
is:        What   are   you   trying   to   say  to  these   people    once   you  reach 
them?      Once   you   define   your  audience,    what    do  you  tell   them? 
There    should  be   a   clear-cut    objective   in  mind  for  any   mass 
communications   effort,    and  you   should   stick    to   that    objective. 
How  many   times,    if   you   can   benefit    from  some    of   our  past    mis- 
takes,  have   we   been   detoured   or  side-tracked  by   some   peripheral 
project    that    gnawed  away  at   our  energies    and   time    with  no 
obvious   benefit   to   our  primary   goal. 

Some    years    ago   we   were    side-tracked  into    sponsoring  a 
national   art    contest   for  the   handicapped.      For  the   better  part 
of  a  year  this  project    clamored   for  almost   exclusive    control   of 
our  staff  time.      We    received   some    remarkable   paintaings    from 
all    over   the    country — enough    to   nearly    force   us   out    of   our 
offices    and   into  the    corridors — but    just    what    did   all   this 
spectacular  effort   avail  us?      It   was   not   clearly  evident   to 
employers   that    being  a   good  painter  was    synonymous   with   being 
a   good  employee. 

The  point   is:      Have   a  high  priority   for  what   you  are 
trying  to   do   or  say,   and  let   everything  lead  to   that    objective 
without    being  deterred   from  your  target. 

It    may,    for  instance,    be   temoting  to   bombard  editors 
or  Hollywood  producers   with  protests  about   the   habit   of   stereo- 
typing people   who   wear   glasses.      In   movies    and  television   the 
leading  man  never  rides   off  into   the   sunset    with    the   plain 
Jane   who   wears   bifocals — never,    that    is,    until  her   glasses 
are   accidentally   crushed  in  the    ground  and  he    discovers    for 
the    first   time   that    she's  not   too  bad  to   look  at   after  all. 

But   lobbying  against    such   entrenched  notions    can   drain 
your  resources,    and   lead  to   questionable    results.      If  you  want 
to  encourage   people   to  have    visual  examinations,    stick   to  that 


117 


objective   and  pour  all  your  energies   in  that    direction   without 
wavering  toward  tempting  tangents. 

Another  basic   question  you   must  answer   is:      What    media 
should  you  use   to   reach   these   people?      In  many   instances,    it 
is    felt   that   a   good  approach   is   to  knock    out   a  press   release 
and   then  sit    back   with    folded  arms.      Or,    many  oersons   with   a 
program  like   to  engage   in  that    favority   occuoation — turning 
out  pamphlets.      Again   it  becomes   necessary   to   make   a   careful 
analysis    of  all  available    media,    and  determine   how  they   reach 
the   groups   you  want   to   reach. 

Do  you  want   to   reach   special  educators?     Perhaps   the 
best   way   is    to   include   your  message   in   the    journals   they   are 
likely   to   read.      Or  perhaps    it    may  be   more   valuable    to   try 
to  obtain  a   spot   on  the   program  of  their  conventions. 

Perhaps   the   mass    media   should  be    shunned  in   favor  of 
more    specialized  types.      Don't   turn   impulsively   to   the   big 
game — Life,    Look,    NBC,   CBS.      It  probably    can't    be    done,    and 
the    results  will  not   warrant   the   effort.      Use   media  as   a  tool 
for  reaching  groups,   but  be   modest   in   your  aspirations.      Don't 
expect   too  much,    and  don't  be    disappointed. 

If  you   want   to   convince   parents   that   their  children 
should  have   yearly  examinations,   who    says    a  pamphlet    is   the 
right   means    for  telling  them?     Perhaps    it   is, perhaps   not. 
Maybe   the    neighborhood   shopping  newsoaper  will   get   a  bigger 
reading  audience. 

With   a  program  having  a   certain   amount    of   social  appeal, 
radio  and   television  broadcasters    will   give    you   donated   time, 
but   don't   expect   many  people    to  hear  you.      It   probably  won't 
be   prime    time.      This    is    an   inevitable   economic    fact   that    must 
be    faced. 

Quite    regularly  the    President's    Committee    receives 
individual   reports    from  radio   and   television   stations,    showing 
how  many   of   our  public   service    spot   announcements   were   aired. 
Over  the    course    of  a  year  we   shuffle   these   around  and  come 
up  with   an  estimate    that   the   nation's    broadcasters    contributed 
one   million  or  two   million   dollars    worth  of   donated  time    to 
the   employ-the-handicapped  program.      Of   course,    we   are    deeply 
grateful   for  their  generosity,    but    at    the    same   time   we    realize 
that    our  iressage   was  not   in   contention   for  the   top  Neilson 
rating. 


118 


Finally,   a   decision   will  have   to  be   made    concerning  the 
content   of  your  message.      What   will  you   say?      There    is   so 
much   competition    for  the    attention   of   the   public   that   your 
entire   message   will  probably  not    be   heard.      Therefore,    it    is 
important,    as    in  any   campaign,    to   have    an  effective    slogan, 
so  that    at    least   this   much   comes   through   loud  and   clear. 
This    slogan   should  accurately   telescope,    within  a    few  words, 
your  entire    message. 

Over  the   years    the   President's    Committee   has   met   with 
success   in   the   use    of  the    slogan,    "It's    good  business   to  hire 
the   handicapped".      There   really    are    solid  economic   advantages 
for  an   employer  to   include   handicapped  workers    on  his   payroll — 
they   are  efficient,    conscientious,   productive,    reliable,    safe, 
steady,   and   loyal  employees.      All   of  these    add  up   to   good 
personnel  practices,   and  take    away   the   element   of   charity  and 
sympathy  which   is   not    always   appealing  in  the   hard-nosed 
business  world.      Our  slogan   sums   up   the   appeal   and   impression 
we   want    to   leave   with  employers. 

Another  essential  part    of  mass  education   is  time. 
Do  not   expect   overnight   results.      Just  when  you  yourself  are 
getting  sick   and  tired  of  the   repetition   of  your  words,    you 
can   begin   to   assume    that   your  message    is    catching   on.      Com- 
mercial  products   in   intensive   promotional   drives    are    repeated 
for  years  before    they  become   household  names.      One   mouthwash 
campaign  has   had  the    same   advertising  appeal   for  20   years; 
a   soap   campaign  has   been  going  on   for  50   years.      If  it   takes 
commercial   interests   that   long,    how   long  will   it   take   a  public 
service   message    to  make    an   imprint   on   the  public  conscience? 

These    are   merely   some   basic   and  elementary   considerations 
involved  in  the   problem  of  reaching  the  people   who  can  benefit 
by  your  services.      But   with  proper  planning,   these  people   .can 
be   reached.      For  their  own   good,    and  the   good  of  their  communities 
they   should  be    reached. 


Washington,    D.C.      20210 


119 


DECENTRALIZING.   LOW  VISION   CARE 
Edwin   B.    Mehr* 

I   am  going  to   take   a   slightly   different   approach  to 
this  problem  of,    "How  do  we   reach   our   visually-limited 
people?" 

The   title   of  my  paper  is    "Decentralizing  Low  Vision 
Care,"      Obviously,   this   is   contrary  to  some   of  the    things 
that   have   been   said  previously   in  this   conference.      That    is 
fine,   nobody  expects   everyone   to  agree. 

Yesterday   morning  on   the    first  panel,   Wallace   Watkins,    of 
Goodwill   Industries,   asked:      "What   are   we   doing  for  the   visually 
handicapped   in  Chilicotti?"      I   don't  even  know  where   Chilicotti 
is,      I   don't  even  know  if  I'm  pronouncing  it  correctly;    but  he 
did  raise  a  very  real  problem.      There  are   a  lot  of  people  out- 
side  of  the   big  cities,   who  need  this  kind  of  help  and  they 
need  it   in  their  own   communities,   and  this,    I   think,    is   some 
of  the   answer  to  reaching  these  people  where   they  are. 

While   repeated  studies  have   shown   that   low  vision  clinics 
can  and  do  successfully  help  approximately  70  percent  of  their 
patients  with  optical  aids,   a  point  that  has   received  less 
emphasis   is   that   multiple    visits   are   needed  to   achieve   this 
result.      For  example,    the    Industrial  Home    for  the    Blind   in 
their  pioneer   study  reported  68  percent   of  their  500  patients 
had  been   successfully   fitted  with   aids  but   also   that   the    over- 
all average  number  of  visits  per  patient   was   4   and  when  an  aid 
was    fitted  it   was   5.      Some   patients  made   as  many   as   10  visits 
to  the   clinic.      Parenthetically,    optometry   is   handicapped  by 
our  typical   success    ratio.      We    do  not   consider  68  percent  a 
good  enough  average! 

Transportation, for  the    low-vision  patient,    is    often  a 
problem.      Typically,   he   cannot    drive   a   car  and  is   handicapped 
in   getting  about    in   strange   areas,    far  from  home.      Often,    he 
has   very   limited  financial  resources  which  also  makes   repeated 
trips   to,    or   long  stays    at,    distant   places  an   impossibility   for 
him.      Dr.    Heller,    our  visitor  from  the   Veterans   Administration, 
raised  the    same   point.      Even  if  he   can   manage   a   trip,    he   is   un- 
sure  that   this  type    of  care   will  benefit  him.      Unfortunately, 
advice    from  his    local  doctor,   who   is   not   engaged   in   fitting  low 
vision   aids,    is   too   often  either  negative    or  discouraging.      If 
the    low  vision   center  is    remote,   he    finds   it   difficult   to   consult 
with   them  to   discover   their  opinion   of  his   suitability  as  a  patient. 


•O.D.,    Chairman,    Committee   on   Aid  to  the    Partially-Sighted, 
California  Optometric   Association. 


120 


One    of  the   advantages    that    optometrists  enjoy  in   caring 
for  the    visual  needs   of  America   is   their  dispersion   through- 
out  the    land   in   smaller  communities,  as  well   as    large    ones. 
All   of  them  have   been  exposed  to  some    ideas,    and   most    of  them 
to   instruction   in   optometry   schools,    on  examining   and  prescribing 
for  the    visually-limited  patient. 

While    this    should   offer  an   opportunity   for  decentralized 
service   to  the  patients,   in   actual  practice    its   effect   is 
often  not    such.      The   average    optometrist    or  ophthalmologist 
feels   that   he    does  not   have    the    special  equipment    or  techniques 
needed   for  this    type    of  patient.      If  he   has   made   any   attempts 
at   low  vision  care   he   has   had   a   few  spectacular   failures,  which 
he    remembers   much  better  than  his    feeble    successes.      Realistically, 
he    does   not    feel   that'. he   will  ever  recover  in   fees   the    substantial 
investment    in   special  equipment   needed  adequately   to   care    for  the 
few  low  vision  patients  he   may   see    in   a  year's    time. 

Oklahoma   and  California  have   evolved  plans   to   convert 
optometric   offices    into   low  vision   care    offices   when   required 
in   order  to   spread   good   low  vision    care   beyond  the   big  city 
clinics.      The    salient    features    of   the  plans   are:      1)    a  panel 
of  well-trained   optometrists   in   the    low  vision    field,   preferably 
with   geographical   scatter.      2)    Mobile   testing  and  demonstration 
units   that   can   convert   any   modern   optometric    office    into  a   low 
vision   office.      3)      Information    on   sources,   powers,    cost,   etc. 
of  various    aids  not    usually  available    from  conventional   opto- 
metric  laboratories.      4)    Education   of   optometrists   and  the 
general  public  about   the   availability   of  these    services. 

The   Santa   Clara  County    (California)   plan  is   the   one    I 
am  most    familiar  with,    having  been    intimately   connected  with 
it    from  its   conception   in   196l   to   the   present.      Under  the 
formidable    title    of   the    Santa    Clara   County   Panel    for  the 
Optometric   Rehabilitation  of  the   Partially   Sighted,    are    listed 
those   members    of  the    Santa  Clara  County   Optometric   Society 
who   wished  to   take    care    of  this   type    of  patient.      They   also 
had  to  take    special  post-graduate    training  and   share    in   the 
cost    of  the   kit    of  special  equipment. 

A   series    of   seminars   was   held   covering  both   theory   and 
practice   and   including  demonstration   clinics.      A  total   of 
eighteen  hours    of   seminars   were    given   by   Dr.    Allan   Freid  and 
myself.      We   hold   with   Dr.    Hellinger  and   the    Industrial   Home 
for  the   Blind  that   technique    of  examination   and  training   are 
more    important  than   the   use    of   special   deviees. 

A  mobile    collection   of  equipment   was    assembled   and  a    large 
carrying   case    (resembling  a   large    suitcase)    constructed   to 
carry   it.      In   this    mobile   unit  are  included   special  charts, 


121 


test    cards,    lenses    and   other   devices   not  normally   found  In 
the    average    optometric    office.      The    contents   were   assembled 
with  the    idea   of  being  able    to  test   almost    any  type    of   partially 
sighted  patient,   and  to  demonstrate   the   appearance    of  the 
finished  device.      There   was   to  be   as   little    duplication   as 
possible . 

Necessary   items   usually    found   in   optometric   offices    such 
as   a  trial   frame   and  trial   lens   sets,    ophthalmoscope   and 
biomicroscope    are   not    included.      More   unusual  equipment, 
such   as    large   print   distance    test    charts   and  reading   cards, 
telescopic  and  microscopic   spectacles,   illuminated  magnifiers, 
binocular  loupes,   and  a    1.00D  Jackson   cross-cylinder  are   in 
the   mobile   unit.      A   complete    list    of  the   contents   may   be    found 
in   the   Oct.    -  Nov.    1964   issue    of   the   Journal   of   the   California 
Optometric  Association. 

By   assembling  this    mobile   unit,    over  $700.00   worth 
of  equipment   was   made   available   at    a  cost   to  each   individual 
of  $27.50. 

Included  in   the   unit   is   a   large   binder  containing 
catalogs   showing  the   availability,    specifications  and  cost 
of  a  great   variety   of  aids.      Also  there    are   special   re- 
ference  books   and  bibliographies.      The    mobile   unit    is 
transported   in   its  entirety  to  the    office    of  the    doctor 
requesting  it   who  can   keep   it    for  one   week. 

There   are,  at   present, 25    members    of   the   panel   in   11   cities 
in  the   County.      This   public   service   project    aroused  interest 
on  the   part    of  the  press    and  T.V.      Their  coverage   resulted  in 
many   inquiries   to  the    society  and   referrals   of  patients   to 
members   of  the   panel.      The   members    of  the  panel  now  offer 
help   to  partially-sighted  patients   in   their  own  offices.      These 
are    in  many   instances  patients   from  their  own  practices   whom 
they  would  have    felt   were   hopeless   in  the   past.      Other  opto- 
metrists  as   well  as   the   general  public  have   heard  of   this   pro- 
gram and   refer  patients  to  panel   members. 

A  two  year  review  based  on   a  questionnaire    sent   to  panel 
members    revealed  that   67  percent   of  the    low  vision  patients 
of  the   panel   members  had   obtained  a   useful   increase    in   vision 
by  the   use    of   low  vision  aids.      This   is    consistent   with   figures 
obtained  in   large   clinics. 

To  summarize:  Decentralized  low  vision  care  is  made 
possible  by  training  panels  of  optometrists  and  providing 
them  with  mobile   testing   units. 


122 


The   advantages  of  decentralizing  are: 

1)  The   service   is  brought   closer  to  the 
patient. 

2)  This    makes   possible    more  thorough  care 
through  more    visits   and  more    frequent 
follow-up. 

3)  A   larger  number  of  optometrists   are 
alerted  to  the  possibilities   of 
helping  the  partially  sighted. 

4)  More    information   is   spread  at   the 
home   town   level   and  potential  patients 
are    reached. 

5)  The  local  optometrist  is  in  a  better 
position  to  know,  talk  to,  and  enlist 
the  aid  of  teachers,  social  workers, 
psychologists,  pediatricians,  general 
practitioners,  school  nurses,  and  any 
others  whose  help  may  be  required  for 
a  particular  patient. 


1240  Scott  Boulevard 

Santa  Clara,  California  95050 


123 


QUESTION  DIRECTED  TO  DR.    MEHR:      Is    the   AOA   Committee 
or  the   Santa  Clara   Group   disseminating  any   information 
to  the    optometric  profession,    generally,    concerning  their 
program? 

DR.    MEHR:      A  two  year   study  was   written  up   in   a   special 
issue    of  the   Journal   of  the   California  Optometric    Association, 
October-November,    1964.      The    largest   extant   number  of  copies, 
that   I   know  of,    are    in   the    Library   of  Congress.      They   just 
arrived  there   a   few  days   ago. 

I   don't   think   there   are   many   others   left   anywhere, 
except    individual   offices.      If  you  want   a   copy   of  that 
issue    it    is   the   October-November,    1964,    Journal   of  the 
California  Optometric  Association,   and   I   think  Mr.    Hagle 
at   the   Library  of  Congress,    Division   for  the    Blind   is   the 
man  to  write   to,   and  he  will,    I   am  sure,   be   glad  to  send 
you  a  copy. 

That   is   what    is   in  print   as   of  the    moment.      The   rest    is 
in  my   head.      I   have   been  assigned   the   project   of  writing 
this  up  and  I   think  AOA  plans  to  issue   it   as   a  pamphlet. 
When  I    stop   talking  and  sit   down   and  start   writing,    one 
of  these   days,    you  may   get    it. 


12  4 


REACHING  AND  SERVING 
VISUALLY-LIMITED  CHILDREN 

i     -  ~  '■         ~  -  -j         -  -     ■   —  i 

J.    William  Oberman* 


In   discussing  the    subject    of   reaching  our  visually- 
limited  people,    I   will   confine   my   comments   to   children.      I 
am,    after  all,    a   member   of   the    Children*  s   Bureau.      We   don't 
have    the    faintest   idea   of  whom  we   are    talking.      All   we  have 
is   some    general    idea   of   the   number   of  children  and   of  the 
fact    that   they   are   increasing  at   a  very   rapid   rate. 

The    1963   census    data    show   36  percent   or  69   million   of 
the   population   of  the   United  States   is   under   18,      By   1975, 
it   is  estimated  that   this  will  be   75   million.      This   is   a 
staggering  number. 

In   i960,   there   were   20  million   children   under  5   years 
of  age.      I   have  heard  it    stated  here,    and  I    certainly   believe, 
we  must  move    to  meet   the    vision  needs    of  this   group   before 
the   children   reach   school. 

There   has  been   another  trend,   particularly   in   relation 
to  the   partially   sighted,    to  which   I   would   like    to  call  your 
attention.      We   are    getting  better  at   salvaging  babies,   and 
we   are   paying  a  higher  price    for   it.      We   are   saving  babies 
that   heretofore   would  have    died.      Many   of  these   babies   are 
perfectly  normal,    but   many   of  them  are   not.      We   have    many 
more    children   who  have    survived,    but    who  have    survived  with 
handicaps   from  a  very   wide    variety   of  causes,   and  we  have 
some    figures    on   that. 

You  may  be    familiar  with   these.      In   a   fairly   recent 
publication  there   appeared  an  analysis    of  causes    of  blind- 
ness   (and  whenever  we   speak   of  blindness,    we   soeak   of  the 
partially-sighted   too).      The    cases    of   blindness    due    to 
prenatal   factors   increased   44   percent   over  a   four-year 
period,    1954   to   1955,    1958   to   1959.      I   think  that   this 
trend  will  continue    for  at    least   two  very  pertinent   reasons. 

One   is    the  nation-wide   rubella  epidemic    that    we   have   just 
gone    through.      We  are    identifying  affected  babies   much  earlier 
(many   of  these   are    blind)    and  we  have   been   able   to   identify 
a  wider  spectrum  of  handicaps.      We   are    going  to   discover  a 
number  who   are   not   going  to  die,    a  number  who  are   not   going 


*M.D.,    Pediatric  Consultant,    Division   of  Health   Services,   Child- 
ren's  Bureau,   U.S.    Department    of  Health,   Education   and  Welfare. 


125 


to  be   very  seriously   handicapped,    but   we   are    going  to  have 
some    cases  who  will  be   moderately   or  severely  handicapped  and 
you  know  visual   defects  will  be   a  very   important   aspect    of 
the    latter.      We   are    getting  a   little    more    sophisticated   in 
identifying  these   children   and  have   to  be  prepared   to  do 
something  about   it. 

Well,   as   you  also  know,   the    disadvantaged   socio- 
economic persons   are    very   much   in  the  news   these    days. 
There   are   a  number   (I   might    say   a  "bewildering"   number) 
of  programs   available    to  them  on  the    governmental   level. 
In   fact,    some    government  agencies   go   through   some    "inter- 
agencies"   squabbling  as  to  which  agency   shall   serve   which 
person. 

Now,   the   poor  person   is  popular  but   it  is   also  true 
that   the    incidence    of  eye   defects   in  his   children   is   much 
greater.      In   one    study,   blindness   and  visual   impairment 
accounted   for  12.4   percent   of  chronic   conditions   reported 
for  families   making  under  2   thousand  dollars  per  year, 
whereas  these   same    conditions   occurred  in  only   6,4   per- 
cent  of  those    with   an    income   of  7   thousand  dollars   a  year 
and  over.      This  is    approximately  twice,    and  is   actual 
evidence   to   show  that   people   of  lower  social  economic 
status   do  have   a  higher  incidence    of   visual   defects.      We 
might  also  add  there   would  be   a  quite    real  possibility  that 
the   visual  defects   would  be   more    severe   because,    If  there 
is   anybody  who   doesn't    get    the   medical   care   that    they  need, 
it   is   in  this    group. 

Well,    I   am  not    going  to   go   into   things    like    our   lack 
of  information   on  which  constitutes   an   adequate    screening 
program  and  how  many   children   are   not   being  screened.      I   don't 
think  that   you  have   this   information  either.      I   think  that 
we  would  just  have    to  continue   to  make   efforts   in   this    dir- 
ection. 

There    is   one   thing  that   I   want   to   stress — and  I   am 
sure    that   you  would  all  agree— screening  efforts   must 
occur  early   in   life.      You  all  know  the    irreversible 
effects  that   can   occur   from  amblyopia  in  pre-school 
children. 

Well,   what   could  we   do  when  we   find  these   cases,    and  I 
think   this  partially-sighted   group   is   the   important   group, 
as   this   conference   has   brought   it    out.      The   blind,   at    least, 
we  have   a   reasonable   chance    of   finding.      Minimal  visual   defects 
we   should  very   much    like   to   find  too   for  reasons  which  are 
self-evident. 


126 


It   is   this   minimal   group  which,    I  have   a   feeling,    is   most 
largely  missed,    and  yet    is   very  much   in  need  of  our   services. 
I   would  only  make    one  point,   and  that   is   that   affection   in 
this   middle    group   is   very   likely  to   lead  to  a   less   severe 
condition,   which  would,    in  effect,    cause   blindness   in   so 
many   from  a   "poorer"    group.      That   is,    the   causes   are    still 
the    same   as  before    but   the    less    severely   disadvantaged  socio- 
economic  group  has   been   less    severely   visually   affected. 

In   Columbus,    they  surveyed  a   large   number  of  people, 
studying  particularly   children   in   the    fourth,    fifth  and 
sixth   grade.      Thirty-six  were    identified  as  partially 
seeing  by  an   ophthalomologist  and  by  an   optometrist,    but 
would  you   listen  to  the    secondary   diagnoses   in  this    group: 
Minimul  neurological  handicapped,   emotional  problems; 
primary  myopic   condition    (which   could  not   be   corrected  to 
better  than   20/70);   epilepsy,   microcephalia,    abnormally 
slow  physically,    agile   mentally   retarded!      Obviously, 
this  partially-sighted  group,    of  all  groups  that  we  can 
identify,    really  needs  a  thorough   going  over  by  quite   a   large 
number  of  people. 

No  matter  who   sees   this   child   first,    he   has   an   obli- 
gation to  check  him  out   and,    as   was   brought   out   very  ably 
by  Mrs.    Kern,    these    children  are   not   a  province   of  a 
single    discipline. 

I   will   close   with   describing  a  couple   of  Children's 
Bureau  programs   in  which   I    think  you  might    be    interested.      You 
are    probably  well  aware    of  the   crippled  children's   program 
in  the   various   states.      These   vary   widely  in  the   kind  of 
conditions   they   accept   and  the   number  of  children   involved. 
Let   me    say  that  this   is    a  resource   available    for  correction 
of   refractive   errors   in   16   states   and  for  care    for  2  7   other 
visual   disorders   in    31   states.      This,   however,    is   really  just 
a   drop   in  the   budget,    due   to   lack   of   funds.      Also,   in   fund  design- 
ation,   other  crippling  conditions   are   viewed  as   being  more    important. 
I   don't   necessarily  agree    with  that,    but    they  were    just   "there 
first" 

However,    I  would   like    to  acquaint  you  with   another  problem 
in  our   legislature,   which   I   think  you  should  know  about.      This 
was   briefly  talked  about   by  Miss  Butts    last  night   in  her  speak- 
ing of  her  program  of  welfare   administration.      These   are   the 
first   programs   she    described  to  you   last  night;    special  health 
project    grants.      These   are    grants   which   are   made    to  various 
states  and  local  health   agencies,   to  medical   schools    and   their 
teaching  hospitals   to  provide   comprehensive   health  care    for 
pre-school  children   and   children   of  school  age,   particularly 
in  areas   of  concentration   of   low  income    families — the    groups 
that   really  need  it    the   most. 


12  7 


These   projects   will  orovide    screening,    diagnostic   and 
preventive    services    for   all   children,    correction   of   defects 
and  after-care,    including   dental   services    for  children   with 
low  income    families   who  not    otherwise    receive   treatment. 
This    is    a  really   comprehensive    care   program.      Sometimes   I 
get   a   little    upset    because   probably  not   available    to  me   are 
the   kind   of   services   that   these   projects   will  provide. 

However,    this    is   a   wonderful   ooportunity   to   really 
get    out    and   dig   for  cases   which   we  haven't   turned  up   and 
provide    the   kind   of   care    we   need.      We    really    look   forward   to 
the    beginning  of   these   projects   with   an   enormous   amount    of 
interest    generated   all   over  the    country   and  we   all   are    very 
excited  about    it,    and   I    hope    that    on   the    local   level   you  will 
try   to   identify   your  profession   with   these    services. 


HEW  Building  4414 

Washington,    D.    C. 


128 


REACHING    OUR 
VISUALLY-LIMITED   PEOPLE 


Caroline    Austin* 


There   have    been   many   many    things   said  today   that    are 
of  vital   concern   to   you   in  your  work,    to   us   in   the    field  of 
public   health,    and   to  education.      Having  taught    school    for 
almost   a   hundred  years   before    I    started  working   in   a  public 
health   agency,    I    feel   that    there    are   many   imolications    from 
an  educational   point    of   view,    and  a   public   health   ooint    of 
view  that    very    often   we    miss    because   we    get    so   wrapped   uo 
and   involved   in  putting  our   sights    on   one    soecific   problem. 

I    would   like    first   to   mention    something  that   Dr.    Oberman 
spoke    of   and   that    is    the   multiply-handicapped  child.      Too 
often  we   categorize    these    children,    put    them   in   a    specific 
group   and  then  handle   them  according  to   that  particular 
difficulty,    forgetting  about   the    other  problems    involved 
more    and  more    as   we    work   with  these    children   we    find   that 
there    is    vision    involvement    in   a    large   percentage    of   them  who 
are    in   any   of   the   programs    of   soecial  education.      I    like    to 
think  that   the   term   visually    limited  means   not   just    the 
serious    visually    limited,    but    any   person   who   can't    function 
adequately  because    of   some    impairment    in   his    visual  process. 
I   think   this   has    been  brought   home    to  me   even  more    thoroughly 
in  a   recent   experience    I   had   in    dealing  with  perceptually 
handicapoed   children,    or  children   who   have   been    labeled 
"perceptually-handicapped".      It    was   a   tremendous   exoerience. 
Tie    are    doing  a  special   study   to   try   to   determine    if   there    was 
a  oattern   that   these   children   showed   in   hearing   loss   or  in 
visual   shortcomings.      You   might   be    interested  to   know   that 
it    was   apparent   that    many   of   these    children    showed   vision 
problems. 

This    leads    right   into   the   need   for  better   screening.      I 
am  not  necessarily   advocating  including  more   things    to   screen 
for,    but    for  better   screening  with   whatever  method   is    used. 
I    think   we  have   been   inclined   to   sell    vision   screening  down 
the    river,    considering  it   is    something  that    anybody    can   do. 
In    fact,    I   even  heard   one    school   superintendent    say,    "We 
could  just    go  out    on  the    street   and   bring  in  the    first 
oerson   we   see    to   do  the    vision    screening".      Sometimes   it 
almost    appears    as    if  this   has    been    done.      The   methods 
that   are   used  are   entirely   dependent   upon    skill,   knowledge, 


*M. A. ,    Vision   Coordinator,    Division   of   Preventive    Medicine, 
Illinois    Deoartment    of  Public    Health. 


129 


and  ability   to  work   with   children   of   the   person   using  the 
instrument,    the    Snellen   chart,    or  whatever  method   is    being 
used. 

I    can't   olead   too    strongly   in   oublic    health    for  better 
use    of   instruments.      We    must    have    screening   instruments 
that    will    find   as   many   children   as   possible   that   will    go 
as    far   as    we    dare    go    in    referring   children    for   definitive 
diagnosis    and  treatment   and   yet   maintain  oarental   resoect. 
This   can   only   be    done    bv   skilled  use    of  these    instruments. 

In   other  words,    we   have    a   commodity   to   sell.      What   will 
the    oublic    buy?      This    is    the    main    thins;  we   have    to   keeo    in 
mind   in   dealing  with    screening  programs    from  a  oublic   health 
point    of   view.       I    think   one    of   our  biggest    problems    in 
dealing  with   this    from  a   oublic   health   area   and  probably 
from  yours    also,    is    that   what   people    want    is    a  oackage   all 
tied   up   with   a  blue    ribbon   around   it.      They   are   a    little   bit 
hesitant   to   look  at    all    the   aspects    in  the   different   angles 
of   any  program  as   to  what    is    usable    and  what    is    not.      Our 
efforts   in   a   community   must   be   to   helo   them  be    selective 
in   order   to   do   the   most    good. 

I    think    one    of  the   orime   examoles   of   this    has   been   the 
Delacato  method   which  has   sweot   the   country    like    wildfire. 
Nobody  has    bothered   in   any    real   significant   way   to    ferret 
out   the    good   or  bad   or  what    is    usable    or  what    is   not 
applicable   to   our   situation.      Pew  have    questioned   the   methods 
used.      Because    it    is   written   down   in   a   book,    is    it    reliable? 
Or   are   there    other   factors   involved?      It    is    a  package 
"guaranteed"   to   produce   and    for  that    reason    it   has    gone    like 
wildfire    throughout   the   country,    unfortunately,  from  my  point 
of   view. 

Changing  completely   to  another  problem;    I    would   like   to 
mention    the    lack   of  oersonnel   to  assist    local  people    in   develop- 
ing sound  vision   programs.      This    is    a  very   serious   matter   in 
the    United   States    and   I    think   in  this    meeting  this    fact   has 
become   even   more   evident.      Right  now   on   my   staff  we   have   two 
positions    open.      They   call   for  a   Masters   Degree    in   Education, 
and  requires   experience    in  working  with   or  teaching  the   blind 
or  partially   sighted   or  with   some   experience    working  in   a 
public  health  vision  program.      These   jobs   carry   good  salaries. 
We    often  think   of  some    of   these   government    positions   as  not 
paying  well,    but   we   can   match  most   of  the   teaching  salaries 
in   special  education   which  are   pretty  high  at    present    in 
most   parts   of  the    country.      If  we   get   anyone   to    fill   these 
positions   we   will   probably    rob    some    school   system  of  a   teacher 
or  administrator. 


130 


Why   is    it   that   we    don't   have    many  people    going  into 
teaching   of  the    blind   and  partially   sighted?      I   think   there 
is    one    very   major   reason    for   it    and   that    is   that    the   teach- 
ing  of  the   partially-sighted   child   or  the   blind  child  has 
never  become   quite    socially   acceotable.      It   does   not    seem  to 
have   the    glamor  that    some    of  the    other  areas    of   soecial 
education    for  young  people.      We   are    going  to  have    to   sell 
young  people    on   the    idea   of   the    service,    and  even   the 
romance,    of  working  with   children    in   this    area.      Goodness 
only   knows   the    need   is    there.      Why   are    talking  in   terms    of 
this    kind   of  person    for  public   health  positions?      Because 
it    is    more   evident   all   the    time    that   we  must    conserve    our 
highly   trained  manpower,    such   as    we    have    in   the    optometric 
orofession   and   ophthalmologic    orofession    or  in   any    field 
of   medicine.      We   must    conserve    our   people    for  the   area   of 
definitive    diagnosis    and  treatment   and   if  we   are    going  to 
do   that    we   must   br-ing  in  the   auxiliary  oeople,    who  are 
well   trained,    qualified  and   respected.      This    profession    is 
a  orofession    of  its    own   with    special   training   far  different 
than   training  in    ootometry   or  even   classroom  teaching. 

This   problem  of  helping  to   locate    and   assisting  people 
in   a   given  community   in   the    area   of  working  with    and   for 
people   that   have    vision  problems,   whether   it   be   a   minor 
problem  or  a   severe    problem  such   as    some    of  those   we   have 
had  called   to   our  attention   during  this   two-day   institute    is 
challenging,    rewarding,    and  we  need  more   people    to   do   it. 


Springfield,    Illinois      62706 


131 


QUESTION    DIRECTED   TO    DR.    GOLDSTEIN:       Is    the   number   of 
visually-limited  people    on   the    increase? 

DR.    GOLDSTEIN:      In   our  Model   Reporting  Area   operation 
we   get    data   only    on   the    legally   blind.      They    are    on   the 
increase    for  a  number  of   reasons. 

The   population    is    aging.      This    means   that   many   more 
people   are    reaching  those    age   brackets   where   certain   chronic 
and   debilitating  diseases    are    common.      We   can   only   expect 
more    and  more    blinding  conditions   in  the    future.      It   seems 
to   me    that    if  this   be    true   as    far  as   the    legally  blind  are 
concerned,    it    would  also   be    applicable    to   the   partially 
sighted   or  visually    limited.      There    is    certainly    convincing 
evidence    from  many   sources   that    the   prevalence    of  oartial 
sight   also  increases   with    age,    and   again,    since   the   population 
is   aging,    we    can   expect   more    of   it. 

QUESTION   DIRECTED   TO   DR.    GOLDSTEIN:      Is    your  Egyptian 
study    relevant    to  the   United   States? 

DR.    GOLDSTEIN:      The    Egyptian    study  has   two   main   objectives 

1.  If  we   were    able    to   set   up    in   another  country   the 
standards   of   securing   data   on  prevalence    that    we   use    in  the 
Model   Reporting  Area   for  Blindness    Statistics,   how  would 
the    data   compare? 

We   were    able    to   do   this    using  the    same    definition   of 
blindness,   the    same    classification    of   causes,    and  the    same 
type   of   data  being  collected  here.      Thus,   we  have  been  able 
to   make    some   preliminary   comparisons. 

I    might    say    that    preliminary   data  shows   the   urban   area 
prevalence    of  blindness   in  Egypt,    the    "land   of   the   blind," 
to  be    seven   times   that    of   our  country,    in  the    rural   areas   it 
is    22    times   that    of  our   country. 

2.  What   could  be    learned   from  this    study   that   could  be 
used  in   our  country   or  in   other  developing   countries? 

We   have    learned  how  to   use    vision    screening  equioment 
in   a  house-to-house    survey.      It   is,    to   my  knowledge,    the 
first   use    of  machine    screening  equipment    in   a   house-to-house 
sample   survey,    the    first   use    of  field  perimetry    in  a   house- 
to-house    survey,    and   the    first    use    of   refraction   to   secure 
best  correction   right   in   the   home.      Attempts    are   made    to 
examine  everyone   in  the  household.      These   attemots  have   been 
most    successful. 


132 


A   ten  percent   sample    of   those    screened  as   non-blind   by 
definition  are    retested   in   an  attempt   to   determine    false 
negatives,    i.e.,    how   many   blind  oersons    are   not   being  picked 
up   by  the    screening  procedures.      To   date,    not   a    single    false 
negative   has   been    discovered. 

We   have    discovered  a    fair  percentage    of    false   positives, 
i.e.,    over- referrals   of  oersons   suspected   of  being  blind  to 
the    ophthalmologist    for   reexamination.      These    over-referrals 
seem  to   indicate   that   the    vision   testers,    in  borderline   cases 
are    inclined,    and   rightly   so,    to    leave    the    final   assessment 
of  blindness   to   the    ophthalmologists. 

We   have    set    uo  periodic    assessments    of  the    reliability 
of   vision   testers    and   ophthalmologists.      This,    to  my  knowledge, 
has   never  been    done   before.      For  instance,    the    same   non-blind 
individuals    are    retested  with   vision    screening  equipment    by 
different   vision    screening  personnel   independently   to  see   how 
the    results   agree.      The   same   blind  individuals    are    diagnosed 
by   a  number   of  ophthalmologists    independently   to    determine 
the    degree    of  agreement.      These   are   periodic   checks   and  will 
continue   as    long  as   the    survey    goes   on. 

After  one   year  in  Egypt,   we   are  already   getting   some 
tangible   benefits   that,    I    am   sure,    will  be    of  benefit   to 
this    country. 


QUESTION    DIRECTED   TO    DR.    GOLDSTEIN    AND    CAROLINA    AUSTIN: 
In  the    field   of   research   is    there    a   recognition   of   the    im- 
portance   of  the    longitudinal   studies    involving  Allied   Health 
Care    Discipline? 

DR.    GOLDSTEIN! :      At   present,    NIND3   has   underway   the    so- 
called  Collaborative   Project,    a   long-term  study    of  some    50,000 
pregnant    women   and    follow-up   of  the    resulting  offspring   for 
six   years.      Of   course,    this    study   should   give    information   on 
multiple   handicaps    and   other   diseases   that    affect    the    children 
and   should  be    able    to   relate    such   handicaps    and   diseases   to 
oerinatal   factors. 


CAROLINE   AUSTIN:      I    think   there    are    several  points   of 
view  which   are    justifiable.      This   is   probably   an   extremely 
important   area    for  consideration   at    the   present    time.      I 
am  sure    we    need   to   find   the    children   as    far  as   screening 
is    concerned,   but   also  we   need  to  have    total  examinations 
available. 


133 


I   had   on   my   priorities    list    of  activities    an   attempt 
to  try   to   secure    funds   which   are   available,    or  have   been 
available,   to  state   health   departments   to   conduct    research 
and   studies    in   this    area.      Because    of  some    unforeseen    cir- 
cumstances,   I   was   not    able   to  put   this    into  effect   because 
of   lack    of  time   to   write    up   the    study,   thus   making  the 
money    available. 

I   think   there    should  be    money    available    for  such    a  study 
which   we    could  apply   both    in  the    screening  of   children,    be- 
ginning in  the   pre-school  years    and  in   carrying  on  with   those 
seen   in  this    study   of  mothers    following  their  children   in  the 
first    six  years.      If  we    could  then   take   those    children   or  a 
similar  group    of   children   on   through  until   they    are   in   their 
teens,   we    really   would  have  a   great   thing  that   is    very   vital 
to  us. 

I   think   this   extremely  important   in   the   area   of  case 
finding.      I   would   like   to  emphasize    the   need   for  these 
registers,   which   has   been  pointed   up    as   another  way   of 
getting  better  material. 

One    of  our  biggest   problems   in   getting   registers 
set    up  is   the    type   of  birth  certificates   that   are   used   in 
most    states.      This    is   the   place   we   need  to   start — to  get 
a  birth   certificate  that   will   give   a   little   more    definite 
information   regarding  the    child   and  his   known  problems   at 
birth.      It   would  be   a   very   valuable    contribution   to   follow 
these   children  through   to  adulthood,    and  it  can   be   done. 


134 


PANEL   5 

"Planning   for  the    Future" 

Afternoon    Session,    March   25,    1966 

Panel    Chairman   -    ALFRED    A.    ROSSNBLOOM,    0.    D. , 
Dean,    Illinois    College    of   Optometry 

****** 

PAPERS   PRESENTED   3Y 

Morton   Davis,    O.D.  ,   Committee    on   Administration 

Agencies,   American   Optometric 
Association. 

Gertrude    Hunter,      M.D.,    Medical   Specialist    for  Head 

Start   Project,    U.S.    Office    of 
Economic   Opportunity. 

Robert   J.    Teare,      Ph.D.,    Senior  Research   Scientist, 

Human   Sciences    Research,    Incorporated. 

John   K.    Dupress,      Managing   Director,   Sensory   Aids 

Center,    Massachusetts   Institute   of 
Technology. 

RESOURCE    PANELISTS 

Joseph   Meyers,  Deputy   Director,   Welfare   Administration, 

U.S.    Department   of  Health,   Education   and 
Welfare. 

Lee    Holder,  Director,    Community   Action  Studies 

Project,    National   Commission   on 
Community  Health   Services. 

J.    F.    Follman,    Jr., Director  of  Information  and  Research, 

Health   Insurance   Association   of  America. 


135 


CLINICAL   OPTOMETRY    LOOKS   AHEAD 


Morton   Davis* 


The   greatest    single   advance    in   the   clinical   care    of  the 
visually   limited  will   come    when   the   two   most    interested 
professions   resolve    their  differences.      They   must    realize 
that    good  care    for  the    visually    limited  requires   both 
professions   working  as   a  team  with   the    other  orofessionals 
involved.      Each   member  must    respect   the    unique   contribution 
of  the    other  member. 

We   have   heard  at    this   meeting    what    many   of   the    other 
professions   can   contribute.      We   all  agree    that   ophthalmology 
is   an   indispensable    member  to   the   team.      Their  unique   role 
is   the   treatment    of  the   pathology,    injury,    or  birth  defect 
that   brought   about   the    limitation   of  vision   in  the   beginning, 
However,    once   the    pathological  processes  have   been   stayed, 
there   are    many   techniques   which  can  help   the   patients  make 
the   most    of  their  residual   vision.      These   techniques   have   been 
developed  by   optometry  and   are    our  unique    contributions  to 
the    care    of  the    visually    limited. 

I  would   like   to   discuss   some    of  these    techniques,    as  they 
are   unique   and   indisoensable .      Dr.    Wisman  has  already   dis- 
cussed training,    so   I   will  keep   my   remarks   on   that   point   brief. 
I   do  want    to  point    out    that   the    specialists   in  physical   medi- 
cine  are   now   doing  the    same    type   of  training  for  other  handicaps 
that   we   have    been   recommending   for  the    visually    limited. 

The    first    job   of  the    ootometrist    is   to  provide   the 
conventional   lenses   which   give    maximum  far-point   visual  acuity. 
If  the    cornea   is   scarred   it    may   take    a   contact    lens  to  neutralize 
the   uneven   refractive   surface   to   get   a  clear  image. 

The    second   step    Is   to   determine    if  enlarging  the    image 
would   be    of  any  help.      When   only   small   objects    like   print   are 
distorted,    a  magnifier   in   the    form  of  a   telescopic   or  micro- 
scopic  lens  may  enlarge   the    image   enough  so  that    the    distortion 
is   not   as   significant. 

When   we   change   the    magnification   of   the    image   we   also 
change   the   person's  perspective    of  things   around  him.      Objects 
look    larger,    so   they   are    generally   judged  as   being  closer. 
Before   we   can   be    sure   a  person   can   wear  his   magnifiers   satisfact- 
orily,   we  must   be    sure   he    can   adapt   to  this  new  perspective. 


*0.D.,    Member,    Committee    on   Administrative   Agencies,   American 
Optometric   Association. 


136 


Magnifiers    for  reading   generally   require   the   patient   to 
hold  the   print   close   to  his   eyes   because   of  the    short    focal 
range.      The   patient,    therefore,   must  be    taught   how  to  control 
the    illumination   so   that   his    own  head   does  not   block   out   all 
of  the    light. 

There   are    distortions   which   cannot   be   eliminated  by  en- 
larging the    image.      Parts    of   the    image    may   be   missing  due   to 
different   types   of  retinal   degenerations,    or  there   may  be 
the   possibility    of  many   different   opacities   in   the    optical 
media  of  the   eye.      Under   these    circumstances    the   patient   may 
not    be   able   to   get   an  entire    form  in   view   at   one    time.      The 
patient    learns   to  segment.      This   is    illustrated  by   a  person 
seeing  one    line    of  the    letter  "A".      He   will   then  try   to 
follow  the    line   to   get   the   entire    image. 

To  be   able   to  do   this   with   any  efficiency,   the    individual 
needs   very   good  control   of  the   movement    of  the   eye.      In    the 
adult    with   good   sight,    a  primary    function    of  these   muscles 
is    to   feed  back   information  as   to  where    the   perceived   object 
is    in   relation   to  himself.      One    reason   I   know  when   a   gentleman 
is    sitting  over  here    instead  of   on   my   other  side    is   because 
my   muscles    tell  me    to  which   side    my  eyes    are    turned. 

With  a  young   child  or  a  person   with   some    visual  handicaps, 
these   muscles   tell  where   parts   of  an   image   are    located  so 
that   they   may   be    mentally    combined   in   their  proper   order. 
Research   on  this   phase    of   development   has    been   done   by 
Zaporozhets,   et.    al.      With   this   in   mind,    it    is   easy   to   see   how 
training  eye    movements    can  bring  about    more   efficient   vision. 

Dr.    Wisman   talked  about   gross   motor  training  earlier.      I 
would   like   to  explain  how   this    contributes   to  the   improvement 
of  visual  performance.      At   one   time,    I   had   the    opportunity 
of  doing  human    factor  reports    for  an  engineering   concern 
working  on   space   projects.      The    astronauts  had  what   were 
termed   "high  I.Q.    retinae".      They    reported  that   they    could 
see    objects  which   were,    based  upon   our  knowledge   of   retinal 
structure   and   function,    theoretically   impossible    for  them  to 
see. 

To   illustrate    where    some    of   this    information   must    come 
from,    I  would   like    to  tell   you  about    an  experience    of   Scott 
Carpenter.      He    reported  that  his    chart    of  the   heavens  was 
reversed.      What   he   did  not   realize   was   that   he   had   let   his 
capsule    roll  until  he   was    upside    down   in   relationship   to 
earth.      The    lack   of   gravity   was  not    giving  him  information 
relating  to   the    direction   in  the    vertical.      Since   he   was 
literally  head   down,   everything  was    reversed.      This    is   just 
one   example    of  the   type-of  information   contributing  to   our 
visual  discriminations. 


137 


To  use   the   parlance   of  the    space   program,    the   optometrist 
is    trying  to   fit    devices  and  use   training  to   get   "high   I.Q. 
retinae"    for  the   visually   limited  so  they   may   receive   more 
information   than   they   do   from  distorted  visual  cues.      We 
are   primarily   interested  in  the  patient's    "information 
retrieval"    system. 

I   was   also  going  to   discuss   the    importance   of   continued 
follow-up   for  the   visually   limited,    but   Dr.    Hunter  said  she 
will   cover  this   in  her  talk.      Instead,    I   will   go   on   to   the 
future. 

None   of  us   can   accurately  say  what   the    future   will  be. 
In  professions  we   get   a  clue   because   the   clinical  procedures 
of  tomorrow  are    the    research  projects   of  today.      I   hope   by 
discussing  some    of  the    research   of  which   I   am  aware,   we   can 
get  a   clue   to  what    future    opt ome trie   care   may   become. 

One   of  the    most    important    studies   in  the    field  of 
low  vision   is    one    conducted  by  Natalie    Barraga.      She   trained 
form  perception   of  low-vision   children   in  the    Texas   school 
system.      She    found  that   she    could  improve,    with   training, 
what   these    children  were    seeing.      This   is   very  important 
in   several  ways. 

It   means   that   we  cannot   even  accept    the   child's   visual 
acuity   as  a   fixed   finding.      We    should  not  put    a  child  on 
Braille   until  we   are    sure   his   vision   cannot  be   improved  to 
the   extent    of  handling  print.      It   opens  up  the   concept  that 
"without   normal   reflexes  we  cannot  expect   the   child  with 
residual   sight   to   develop   his   vision  anywhere   near  its 
capability".      Therefore,   we  can  predict   that   care   of   these 
children  will   change    like    the   care   of  the    orthopedic   child 
did  after  Sister  Kenney   discovered  physical  therapy. 

Harold  Haynes   is   doing  studies   on   visual  development 
in   infants.      Studies   along  this    line   are   taking  place    all 
across   the   country.      Those   with  which   I   am  most    familiar  are 
being  done   at   the   National   Institutes   of  Health  and  the 
Behavioral  Research   Institute. 

At   the    Christ   Church   Child  Center  in  Bethesda,   a   study 
is   taking  place    to  determine   the    value   of  using  teaching 
machines  to  teach   form  perception   to  the   perceptually 
handicapped   child.      The   Reverend  Schuetze,    who   gave   the 
invocation  yesterday,    is   the   pastor  of  the    church  that 
sponsors   the    Christ   Church   Child  Center. 


138 


You  have   heard  new  and   imaginative    sensing   devices 
described,    designed   to   supplement   visual   stimuli   with 
auditory    and/or  tactile    clues.      It   was    discussed  yesterday 
how  these    devices    can   be   used  to   help   with   reading.      Research 
is    being  done    to  see    if  these    devices    can   also   be   worn  to 
help   with   mobility. 

Dr.    Sloan   mentioned  the    use    of  a   red   contact    lens    and 
what    it    can   do.      The    use    of   color  in   changing  the   environment 
for  the   person  with   chromatic    difficulties    is    another   interesting 
area. 

One    imaginative    study   being  proposed   is    the   use    of   a 
specially   devised  harness   to  make    congenitally  visually- 
handicapped   infants   more    aware.      The    rationale    is    that   if  the 
child  has    a  defect,    his    threshold   for  that    sense   will  be   high; 
that   is,    there   will  be    a   deprivation   in  that   sense    modality. 
Any   deprivation   affects   the   development    of  that   phase    of   the 
infant's   behavioral   skills. 

The   proposed  project    is   to  develop   a  harness   that    would 
be   very    flexible    and   fit   an    infant   without    restricting  his 
movements.      There    would  be    a   light   and  a   sound   source    at  each 
of  the    child's   extremities.      The    light    and   sound  combination 
should   make    the    child   more    aware    of  his    body  parts   and  help 
him  stimulate   himself   at   an  earlier  age.      This    should  help 
reduce    some    of  the    retardation  that    is    secondary   to  congenital 
visual   defects. 

The   project   with  which   I    am  most   familiar  is    the    development 
of  Visual   Braille.      "Visual  Braille"    is   an   alphabet   with   the 
letters    designed   to   have    forms   minimizing  confusion   to  a 
visually-limited  person. 

I   mentioned  earlier  how  some   visually-limited  people-  segment 
a   letter  when  trying  to   read.      In   some    of  our  research   we    found 
many   of  these   people   would  become    confused  when  they   came   to 
two    lines   that   branch   off,    one    from  the    other;    they  would  not 
know  which   branch   to   take.      Ordinarily,   people    would  have    a 
view   of  the    whole    letter,    but    with   a   visualiy-limited  person, 
parts   of  the    letter  would  be    missing.      Under  the    latter  conditions 
an   "0"    can   become   a   "C"    or  a   "U",   etc. 

We    decided   to   design   an   alphabet   with   a  minimum  amount 
of  forks   and   gaps.      In   doing  a  search  of  the    literature,  -we 
found  many   alphabets   had  been   designed  with   similar   criteria 
in  mind.      The   Moon   Alphabet    is   still  being  used  to  publish 
material   in  England.      Most    of  these   alphabets    fell   into  disuse 
when   Braille   became    internationally   standardized. 


139 


One    of  the   unique   qualities    of  Visual   Braille    is   that 
the    general   form  of  the    letter  is    the    same   as   the   pattern 
of   the    dots   in  Braille.      We   just   connected  the    dots   in   such 
a  way   as   to  produce   no    forked   lines   and  as    few   gaps    as 
possible  . 

Prom  our  pilot    studies   we   have    found  that   the    simpler 
the    visual   form,    the   easier  it   is    for  a   child   to  learn. 
We    found  elementary   school   children   with    good   sight   could 
learn   this    alphabet    faster  than    other  alphabet    forms,    such 
as   the   Morse    Code. 

Any   person   who  knows   Braille    and  has    adequate    sight 
could   read  Visual  Braille    in  a  matter   of  minutes.      Visual 
Braille    seems   to  be    a   good   method   of  teaching  sighted  oeople 
the   Braille    forms.      There    are    sighted  people    who  apparently 
have   trouble    getting  the   segments   or  dots   together  in  order 
to   remember  the    letter   forms.      When  the    dots    are    connected, 
one    apparently   has   much    less    difficulty   committing  the 
form  to  memory.      People    can   then   read   the    dots   with    less 
trouble . 

At   the    suggestion    of  John    Jones,   we    tried  Visual   3raille 
on   retarded   children.      These    children   had  had  trouble    recognizing 
the    regular  alphabet.      We   made    cards   with   likes    and   differences 
on    them.      A   typical  example   would  be    one    card  with    four   "A's" 
and   one    "B"    in   Visual   Braille.      There   would  be    a   corresponding 
card  with   capital  block   letters    in   the    same    order.      The 
children   were    instructed  to  pick    out    the    different    letter. 
They    all   did  better   on   Visual   Braille. 

Going  back   to  other  research  projects,    I   would   like    to 
mention   that    I   agree    with  what   Mr.    Gallozzi   said   this   morning. 
What    we   need   is    a  Visual  Efficiency   score    to   replace    the    old 
Snellen   acuity   score.      Leo   Manas   of  Illinois    College    of   Optometry, 
has   been  working  on  such   a   scale   and  has   printed  a   scoring  sheet. 

I   only  hope   that    if  a   visual  efficiency   score    is    developed, 
people    will   accept    it   as    a  measure    of  what    the   person    can    see 
at   that   time.      We   have   no   tests    to  measure    a  person's   undeveloped 
abilities. 

An   example    of  what   harm  a   score    can   do   is   best   illustrated 
by   a  young  boy  who  was   brought   in    for  a   check-up.      He   was   being 
taught   only   in   Braille   because    of   his  poor  visual   acuity.      We 
noticed  the   boy    apoeared  to  be    studying  the    titles    of   some   books 
on   a   shelf.      When   we   questioned  him,   we    found  that   he   had  taught 
himself  to    read  visually.      He    didn't    want    anyone    to  know  because, 
according   to  his    acuity   score,    he    was    only   supposed   to   work   in 
Braille. 


140 


I   realize   the   visual  efficiency  score   is   meant  to  eliminate 
that   sort    of  injustice.      I   just   want   to   call   this   to  your 
attention   so   that   one    injustice    is   not   replaced  with   another. 

With   all    of   these    frontiers   being  opened  up   by   research, 
there    is    reason   to  believe    the    team  approach   will  be    able 
to  do   for  the   visually   limited   what   physical   therapy   did 
for  the   oolio  victim. 


4304   East-West  Highway 
Bethesda,    Maryland     20014 


141 


REFERENCES 


Betts,   S.    A.,    Foundations _pf _^Rea.din p;   Inst ruct i on .      American 
Book   Co.,    1954. 

Bier,    N.      Correction  _of    Subnormal   Vision.      Butterworths , 
London.       19£>0 ." 

Blind,    the    Industrial   Home    for.      Optical  _Aids__Service    Survey. 

The    Indistural    Home    for   the    Blind.       Brooklyn,    N.    Y.       1957. 

Davis,    Morton.      "Case    History   of   Ootometric   Care    of  a   Re- 
tarded Child."      Journal  .of   the    American    Cytometric 
Association.       St"    Louis,    Mo.       Vol,    35 ,"  No.    6. 
June,"   196  4." 

Dekaban,    Anatole.      Neurology__of  .Infancy.      Williams   and  Wilkins 
Co.,    Baltimore.      1959. 

Feinbloom,    William.      Technique  _of  Examination   of  the  .Partially 
Blind   Patient.      Published  "by   Designs    for  Vision,    Inc. 
Mew  York,    N.Y. 

Gesell,    A.,    Ilg.    Frances,    and   Bullis,    Glenna.      Vision , 
Its    Development    in   Infant    and   Child.      Harper 
Brothers.       Mew   York,    1950. 

Get  man,    G.    M.      How  to    Develop   Y.our  Child' s__  Intelligence  . 
The    Announcer   Press.       Luverne ,    "linn.  ,    195^7 

Harmon,    Dare  11    Boyd.      Hotes    on  _a  ^Dynamic  .Theory   of  Vision. 
Published  by    the    Author.      Austin,    Texas,    19 5" 8."" 

Hebb,    D.    0.      The    O^ganiz.ation  .of  Behavior.      John   Wiley    & 
Sons.      Hew  York,    1949. 

Hellmuth,    J.      Learning  Disorders.      3ernie    Straub   and 
Jerome    Hellmuth   Co.,    Seattle,    Washington,    1965. 

Herrich,    Judson  C,    The  .Evolution,  .of  Human.  Mature ._     Harper   & 
Brothers.      Mew   York,    Hew  York,    1 96 1 . 

Ilg,    Frances   L.      School   Readiness.      Harper   &   Row,    Hew   York,    1964. 

Jones,    John   Walker  and   Collins,    \nne    P.      Educationa.l   Pro.gra.ms 
for  Visually  Handi_caoned__Children.      Government    Printing 
Office. 


142 


Keohart,   Newell  C.    The    Slow   Learner  in  <the    Classroom. 

Charles   S.    Merrill   Books,    Inc.      Columbus,    Ohio,    i960. 

Montessori,    Maria.      Dr.    Monte s so ri '  s  .Own   handbook. 
Fredrick   H.    Stokes    &    Co.      New   York,    1914. 

Montessori,    Maria.      The    Mont ess  or i    Method.      Translated  by 

Anne    E.    George.      Fredrick    4/   Stokes    &    Co.       New   York,    1912. 

Mussen,    P.    H.      European   Research   in  .Cognitive  .De_ve_lopment . 
Monograph   of   the    Society    for  Research    in  Child 
Develooment.      University   of  Chicago   Press. 
Chicago,    111.,    1965.      Vol.    30,    No.    2. 

Piaget,    J.      The    Origins   of   Intelligence,  in  Children.      Trans- 
lated by  Margaret   Cook.      International   University   Press, 
Inc.      New   York,    1952. 

Renshaw,    S.      Psychology   Paoe.rs.      Ootometric   Extension   Program. 
Duncan,    Ok  la.      194 0-6 0. 

Sen  den,  M.  von.  Spacei  _and  .Sights  the.  Perception  of  Space 
and  Shape  _ln_  the  Congenit  ally.  31ind  ..before  and  after 
Operation.      The    Free    Press.       Glencoe,    HI.,    19^0. 

Strauss,  Alfred  A.  and  Lehtinen,  Laur  S.  P s y ch o 0 at h o 1 o gy  an d 
Education,  of  the  .Brain- Injured  Child.  Crune  &  Stratton. 
New  York,    19  4  7. 


143 


PROGRAMS    OF   THE 
OFFICE    OF   ECONOMIC    OPPORTUNITY 


Gertrude   Teixeira   Hunter* 


Thank   you,    I    am  very   pleased   to  have   been   invited  to 
address    the    group    this   afternoon   and  when   I   was   trying   to 
plan   what    I    would   talk   about,    I    thought   I    should   include 
not   just    discussion   of  Head   Start,    but    the    many   ramifications 
and  needs    for  health   services   in   the    other  Office    of  Economic 
Opportunity   Programs. 

The    War   on   Poverty   came    into   being  very   rapidly.      It   was 
conceived   in    1964,    and   it    was   activated   within   a    few  months 
time.      The    Office    of  Economic    Opportunity  has   many   programs 
directed  toward   alleviating  ooverty. 

The    Job   Corps,    a   major  youth  program  in  the    President's 
War   on   Poverty,    provides   the   basic  education   and   work    skill 
training  to   make   employable    out-of-school   and   out-of-work 
young  men   and   women    16   through   21.      These   youth   receive   a 
monthly   living   allowance,    medical   and   dental   care,    room  and 
board,    work   clothing  and  a   modest    allowance    for   dress    cloth- 
ing  and   $50    for  each   month    of   satisfactory   service.      From 
this    $50,    enrollees   may    allot   up   to   $25   a   month    for   depend- 
ents  or  oarents.      This   sum,    in   turn,    is   matched  by   the 
government . 

The    Job  Corps    marshalled   the    resources   of   the    business 
community,    universities,    agencies    concerned  with  conserving 
natural    resources   and   others   to   create   this    unique    residential, 
educational   program.      It   offers   individual   tutoring  and  counsel- 
ing,   both   formal   and   informal,    day   and  night. 

Vista  Volunteers,   Volunteers   in   Service    to   America,    provide 
an   opportunity   for   those    18   and   over  to   join   the   War   on   Poverty. 
Volunteers  will   work   with   migrant    laborers,    on    Indian   reservations 
in   urban   and  rural    community    action   urograms ,    in    slum  areas, 
hospitals,    schools   and   in   institutions    for  mentally   ill   and 
retarded.      The   period  of  service    is    one   year.      Volunteers   will 
receive    a   living  allowance    and   $50    a   month.      Plans    call    for 
5,000   Vista  Volunteers. 

There    are    lawyers,    mechanics,    students,    housewives, 
ohysicians,    carpenters,    teachers,    farmers,    nurses,   business 
executives,    social   workers   and   retired  military   men.      Also, 


*M.D.,    Medical   Specialist,    Head   Start    Project,    U.S.    Office    of 
Economic   Opportunity. 


144 


a   growing  number   of  Volunteers   are    coming  directly   from  the 
ranks    of  the   Door,    bringing  with   them  a  profound,    hard-won 
knowledge    of  poverty   and  a   commitment   born    of  oersonal 
struggle.      Volunteers    go  where   they   are    invited — and   serve 
under  the    direct    supervision   of  the    local   agencies   to   which 
they're   assi gne d . 

Community  Action   Programs   Drovide    financial    support    for 
local   anti-poverty   campaigns   in   urban   and   rural   areas,    on 
Indian   reservations   and  among  migrant   workers.      Possible 
projects   in   local   anti-poverty  programs   include:      remedial 
reading,    literacy   instruction,    job  training,   employment 
counseling,   homemaker  services,    Job   development,    vocational 
rehabilitation,    establishment    of  neighborhood  health   centers, 
among  others.      This  program  enables   communities   to  attack   the 
network   of  problems   with   matching  positive,    varied,    coordinated 
programs.      Federal   assistance    depends    on   the    community's 
determination   to:       (1)    mobilize    its    own  Dublic   and  private 
resources;    (2)    develop   programs    of   sufficient    scope   and   size 
that   promise   to  eliminate   the   causes   of  poverty;    (3)    involve 
the   poor  themselves   in  developing  and  operating  the   anti- 
poverty  attacks;   and    (4)   administer  and  coordinate   the 
community   action   programs   through  public   or  private   non- 
profit  agencies,    or  a  combination    of   these.      The    federal 
government  pays   up   to   75   percent   of  cost   of  local  programs   in 
first   two   years;   after  that   assistance    is    on   50-50   matching 
basis.      A   significant   part   of  CAP   is   that    these   programs   are 
developed,    conducted  and  administered   with  the    maximum 
feasible   participation   of  the   poor  themselves. 

Other  programs    offered  are: 

The    Neighborhood  Youth   Corps 

The   Work-Study   Program 

Adult    Basic  Education   Program 

A   Work -Experience   Program 

Special   Programs   to  Combat    Poverty   in   Rural   Areas 

Assistance    for  Migrant   Agricultural   Workers   and 

Their  Families 
An  Employment   and   Investment   Incentives   Program 

Project   Head  Start   was   initiated  and   designed  to  meet 
the   needs   of  children    from  poverty  backgrounds   at   the   most 
formative    stage    of  their  lives,    namely   their  pre-school  years. 
During  this  period,   the    creation  of   learning  oatterns,   emotional 
development,   and  the    formation   of  individual  expectations  and 
aspirations  take   place   at   very   rapid  pace.      It    is   now  that 
lasting  attitudes   and  habits   are   established. 


145 


Head   Start   must   help   the   whole   child;  help  him  in   school, 
in  the   home    and  in   the    community.      The   cultural,    medical, 
social   and  educational   care    of  pre-school   children  born   into 
disadvantaged  circumstances,    relates   directly   to  their  future 
lives.      It    is   the    foundation   upon   which   their   full-term 
education,    their  employment   potential   and,    frequently,    their 
good  health  and  social  well-being   is   based. 

To  meet   these   total  needs,    the   program  must   contain 
five    basic   components: 

Education 

Nutrition 

Parent    Involvement 

Social   Services 

Health   Services 

Head   Start   in    summer   of   1965    was  olanned   for  one   hundred 
thousand   children   at   an  estimated   cost    of   seventeen   million 
dollars.      It   ended  up   with   over   five   hundred  thousand   children 
being  involved   in  the   program  at    a    cost    of  eighty-five   million 
dollars.      It    is    not   just   the    children   themselves,    who   are 
involved,    but   there    is   active   participation  by  parents,    the 
educators,    the   professional   grouos   who  have    to   render  the 
services,    the    volunteers   who   come    from  all   social  and 
economic   levels.      There    is   a  place    for  everybody   in   this 
total   community   concept    of   community   action. 

Because   the   pilot  project   was    so   successful,    the    Public 
Health   Service   has   continued   it    into  the    1965-1966   year  in 
three    different    forms.      First,    there    will   be    a   1966    summer 
program   for  about    the    same   number  of   children   who  had   the 
program  last   summer.      Secondly,    are   the    full   year  programs. 
Thirdly,    there    will  be    follow-uo   programs   which   provide    re- 
medial  services    for   children   who  have   oarticioated   in   the 
summer  programs. 

Health   Services.      The   health   comoonent    of  Head   Start 
is    comprehensive    in   nature,    and   includes   diagnostic, 
preventive,    curative    and   rehabilitative   services.      It 
provides   a   medical  evaluation   of  each   child,    including 
screening  of  hearing,    speech,    and  vision,    tuberculin 
testing,    laboratory  orocedures   and   completion   of   immunizations. 
Psychological  evaluations   are    carried   out    where   needed. 

Initially,   the    Office    of  Economic   Opportunity  paid   for 
diagnostic   procedures   and  immunizations,    while    the    costs 
for   follow-up    and   treatment   were   assumed  by  established   local 
agencies.      It   became    obvious,    however,    that    in   many    communities, 
facilities   were    unavailable,    or  were    inadequate    to   meet    the 
health  needs    of  children    in   poverty. 


146 


To  ensure   that    identified   diseases    are   treated,    Head 
Start    programs  now  provide    supplementary   funds    for  complete 
health   care    services,    when   communities    cannot    fully   assume 
these   costs. 

The    referral  and   follow-up  phase   is    a   most    crucial    one 
and   an  area  in   which   perhaps   Head  Start    can  make   a   significant 
contribution    in   bridging  the    gap   between   detection   and   correction. 
Here    in  conjunction   with  established   social   service   and  public 
health  nursing   agencies   can   be    trained   a  core    of  neighborhood 
workers   and   social   service   aides   who   will   work  with   the    family. 
At   this    point   health   education   can   be    most   meaningful.      An 
understanding  of  what    factors   prevent   utilization   of   facilities 
can   be    developed  and   solutions    found    for  their  correction. 

Health   services   should  be    rendered   in   a  manner  that    con- 
fers   dignity   on   the    child  and  his    family    and   indicates    true 
concern   for  his   welfare.      This    rules    out    such   practices   as    com- 
plex procedures   in    obtaining  service,    unreasonable   waiting 
period,    unnecessary   delay   in    referrals    and   in  delivery   of 
service,    and   use    of  second-rate    facilities. 

Research   and  evaluation   is    an   integral   of  the   Head 
Start    program.      A   good  reporting   system   of  health   findings 
is   essential.      We    may  then  establish  the   true   prevalence   rates 
of  such   conditions    as   amblyopia  and   other   diseases    of   child- 
ren  and  we   hopefully   will   obtain   information   on   the    reasonable 
costs   for   comprehensive    care. 

Various  methods    for  providing   care    and   follow-up    can 
be    described  and   made   available   to    communities   planning 
future   programs. 


1200   Nineteenth   Street,    M.    W. 
Washington,    D.    C. 


117 


PSYCHOLOGY    LOOKS    AT    LOW   VI3I0M    R55ZARCH 
Robert   J.    Tea  re* 

During  the    course    of  this    conference,   many   points   of 
view  have    been  expressed  by   the    various  professions   reoresented. 
At   this    time    I    am  speaking  as   a  psychologist,    to  an   audience 
which    consists   orimarily    of   optometrists.      Although   I    am  always 
stimulated  by  these    inter-disciplinary    conversations,    T   always 
approach   them  with   a   certain   amount    of   caution. 

In   some   cases,    they    can   take   away    from   rather  than   add 
to   understanding  among  professional   groups.      This    usually 
stems    from  two    causes:      (1)    a   failure    to   appreciate    the    problems, 
orientation   and  point    of  view   of  another  profession;    and    (2)    a 
tendency   to   soeak   in    language    or  jargon   that    is   unique    to,    and 
therefore    intelligible    only   to,    one   profession.      Being  well 
aware    of  the    fact   that   psychologists   are    often   viewed  as 
mystics   who   soeak   in   a   strange   tongue,    I    shall   do  my   best    to 
avoid  the   pitfalls   alluded  to   above. 

It   has   been   suggested   that   I   talk    on   the    subject    of   re- 
search  in   human   engineering.      That    term  has    a  special   meaning 
within  the    purview   of  the   psychologist;    I    shall   talk   about 
this    in   a   few  moments. 

As   we   shall    see,    human   engineering  is   but    one    facet    of 
crystal   of  inquiry   within   psychological   research.      I   should 
like    to  broaden   the    mandate    given   to  me    and   soeak  about   a 
number  of   research    areas    in  psychology. 

This    session   has    been  asked  to   discuss   olannine;   for 
the    future    in   the    light    of   certain   aspects    of  oast   and  present- 
day   research.      I   ivould   like   to    describe   the    characteristics    of 
this    research  history,    at    least   within  psychology,    by   telling 
this    story. 

It    seems   that    during   a  very   long  but    uneventful   air- 
lines   flight,    the    voice    of  the    pilot    came    over  the    loud- 
speaker in  the   passenger  cabin.      He    said,    "This    is    the   pilot 
speaking.      I   have    some   news    for  you.      Part    of  the   news    is   bad 
and  part    of  it    is    good." 

"I'll   tell   you   the   bad  news    first.      Our  navigator  says 
he    is   not    quite    sure    where   we    are    and,    consequently  we   may   be 
going  in  the   wrong  direction.      Nor   for  the    good  news.       I   am 
pleased  to    report   that,    over  and   above   the    uncertainty   about 
our  present    course,    we    are    really  making  excellent    time." 


*Ph.D.,    Senior  Research  ,. Scientist ,    Human   Sciences    Research, 
Incorporated. 


148 


When   I   use   this    somewhat   humorous   anecdote,    I    do 
not   mean   to   imoly   that    the   oast   has   been    filled  with   wasted 
effort   and  meaningless    findings. 

On   the    contrary,    we   have    made   excellent   progress   in 
many   areas   of   low  vision    research   in  psychology    and  human 
engineering.      Unfortunately,    a   good   deal   of  this    research   has 
not   lent    itself  to  the    solution    of   the   problems    of  the   target 
group   under  discussion   at   this    conference.      The   explanation 
is    fairly   straightforward. 

As   most    of  you   well  know,   the   bulk    of    formalized 
research    in  psychology    and   its   allied   disciplines   has    con- 
centrated  on    clients   with   more    severe    loss — the    legally   blind. 
As    a  matter  of   fact,    this    is    true    of  my   own   research   activity. 

There    are    some    good   reasons    for  this: 

(1)  Research    facilities,    agencies,    and   instrumentalities 
designed  to   provide    services    to  these   peoole    are   more   numerous; 

(2)  Research   subjects   can   be    more   easily   identified 
and   contacted; 

(3)  The   needs    of   this    group   have    seemed  more   pressing 
than   those   with   lesser  degrees    of   loss; 

(4)  Severe   and   total   vision   loss    have    represented 
"cleaner",    more    sharply    delineated  phenomena   for  investigation. 

As    a  result,    from  the    standooint    of  osychology   and 
human  engineering,    only   a  small  theoretical   and  empirical   data 
base    can   be   brought    to  bear   on   the   problems   of  the    visually- 
limited   group. 

Let   me   take    some   time    now   to  explain   this   point   and 
trace    out    its    implications. 

Engineering  psychology   or  human  engineering,    as   it   is 
more   commonly   called,    deals   with  the    scientific    study   of   the 
relationship   between   man   and   the   machines   he    develops.      Some 
of  these   machines   extend  the    intellectual  and  cognitive 
abilities    of  man;    others    amolify    or   replace   his    sensory 
capabilities.      In   working  with   problems   presented  by   the 
total   loss   of   vision,    human  engineers    have   attempted  to 
design   "hardware"   that   will   substitute   tactile    and/or  auditory 
channels   for  those    which   normally  provide   visual   information. 


149 


These    research    studies,    primarily   involving  electronic 
amplification   and   conversion    of  the    visible    soectrum,    have 
been   comprehensively   summarized   in   a   section    of   a   recent 
book   called   "Human   Factors    in  Technology"    (Bennett,   et.    al., 
19b3).      Of  more    direct    relevance   ars    those   efforts   which    are 
designed  to  provide    greater  dire  ct    access    to   visual   stimuli 
through   improved  techniques    of   optical    magnification. 

As    we    have    seen    from    some    of   the    discussions    in    the 
earlier   sessions,    many    strides    are    being   made    in   these    areas. 
Excellent    summaries    of    research    in   low   vision    ootical   aids    can 
be    found    in    articles    such    as    those    by    Davis    (1952),    Gordon 
(1957),    and   Linksz    (1956). 

Regardless   of  whether  we    are   talking   about    sensory 
substitution    or   sensory   amplification,    our-  efforts   with    low 
vision    groups    are   having   less    "pay-off"    than   they    might    other- 
wise  provide. 

Some    of  this    lack    is    due   to  the    fact    that    we    are   not 
able    to  extrapolate    research    findings   which    are   based  on 
groups   with   more    severe    vision    loss.      This   problem,    which 
stems    from  target    rrroup  emohasis,   we   have    already   discussed. 

However,    another   impediment    cuts    across    research   at    all 
levels   of   low   vision.      Because    it    is    a  theoretical   issue    and 
it    undercuts    one    of   the    requisite    concents    of   sound   human 
engineering,    I'd   like    to  develop    the   ooint   carefully. 

The    ideal   interrelationship   between   man   and   machine    is 
based   on   the    concept    of  "compatability" .      All   man-machine 
interactions   involve    an   information   exchange.      In   order   for 
this    information   to    be    of   maximum  value    to   the   human    re- 
cipient,   however,    it   must   be    made    available   at    the    right 
moment,    be    of  the   proper  magnitude,    and  be    of  the    form  most 
appropriate    for  use. 

Only   when   a   machine    can   do  this — provide    the    right    in- 
formation  in   the    right   place    at    the    right   time--can   it   be 
said  to  be   truly   "compatible"    with    its    user.      When  this    in- 
formation  consists   of   a  visual   stimulus    from  the   external 
world   and   is    filtered  through   an   optical   system  to   an    individual 
with   an   impoverished  history   of  visual  experience,    how    do   we 
determine    what    information   to    give   him? 

The    answer  to  this    question    is   not   as    straightforward  as 
it  might    seem  at    first.      A  human   being  does   not   passively 
record   sensory   information,    he   processes    it.      He    imposes 
various    concepts — form,    color,    distance,    movement — uoon   the 
visual  energy   he    receives. 


150 


This    organization   of   stimuli   and   the    derivation   of 
meaning   from  it    is    called   "visual  perception"    by  those 
psychologists   who   study   it. 

Although   research   in   visual  perception  has   been    going  on 
for  many  years,    its    laws    and  principles    are   based  primarily 
upon   data   drawn    from   individuals   who  possess   healthy    and   intact 
visual   apparatus. 

At   the   present   time,    there    is    little   basic   data  which 
helps    us   to   understand   the    role    that   these   perceptual   laws 
play   in    organizing  degraded   visual   information.      Studies    that 
are   now   being  carried  out   are    beginning   to   demonstrate    the 
crucial   clinical   value    of  these    data.      An   excellent   case    in 
ooint    is    the    recent   monograph  by   McLaughlin    (1964).      Studying 
the    strabismus-amblyopia   snydrome,   McLaughlin   presents  evidence 
which   indicates   that   strabismic   adaptation   may   take   place    through 
an   anomaly   of   visual  perception.      Unable   to   develop  normal 
binocular  vision   because    of  oostural   characteristics    of  the 
eyes,    it    seems   that    the   patient    develops    functioning  monocular 
vision  by   "supressing"    the    images    of   the    strabismic   or  amblyopic 
eye. 

These    images,    though   seen,    are   perceived   as   being   "unreal". 
Because    of  its   history   of  adaptive    value,    this   perception 
continues   even   after  mechanical   or  surgical   correction. 

By    lessening  the    real-unreal   distinction   through   special 
techniques,    McLaughlin  was   able   to   provide    a  number   of 
patients   with   ".    .    .an  effective    adjunct   to  the   use    of  surgery 
and  eye    glasses    in   the    treatment    of  strabismus". 

Time    does   not   permit    me    to  elaborate    on   other  asoects 
of  this    theme.      I   think,    however,    that    the   point    has   been 
made . 

Psychology   and  human  engineering  must    devote    much   more 
energy   to  the    study   of  perception   among  low  vision    groups. 
We   must    determine   how  those    stimuli   which    can  be    received  are 
organized,    how   this    organization  varies   with   different   types 
of  deprivation,    the    role    of   onset    age    and  early  experience, 
and  how   this    organization   can   be    modified   over   time   by   means 
of   sensory   augmentation   and/or  training.      Only  then   can   we 
design   ootical   aids   or  institute    clinical  Drocedures    that    will 
best   meet    the   needs    of   the    low-vision   oatient. 

In   the    time    which   does    remain,    I   would    like    to   talk 
briefly   about   one    more    area  where    I    think  we    can   profit   greatly 
from  concentrated   research   effort.      No  doubt    it   is    related   in 
part   to  the    first   topic   but    there    may   be   merit    in  aoproaching  it 
from  another  avenue. 


151 


For  a  number   of  years,   rehabilitation  oersonnel  have 
been   using  the   term  "visual  efficiency"   to   describe   a   rather 
persistent   phenomenon.      This    pertains   to   the    fact    that    some 
low  vision   clients   are    able    to    function   much   more   effectively 
than   others   who,    on   various   standard   measurement    techniques, 
possess    the    same    amount    of   remaining  vision.      In    other  words, 
they   are    able    to    use   what    little    information   is    available    to 
them  in  a   much   more   efficient   manner.      This    difference    in 
functioning  manifests   itself  in   a  number  of  very    critical 
areas   of  activity   such   as    job   performance    and   general 
mobility   level.      To   the   best    of   my   knowledge,    no   definitive 
studies   aimed   directly   at   this   phenomenon  have    been   carried 
out. 

There    are    a  number   of  important    imolications    and 
potential  uses    to  which    research    findings    in  this    area 
might  be   put.      If   the   phenomenon   truly  exists,   this    means    that 
there   may   be    a   meaningful   difference    in  the   prognosis    given  to 
a   low-vision  patient    depending  upon   the    type    of   data  we    obtain 
on  him  and  make   available    to   others. 

This   suggests   something  about   the    sensitivity   and 
validity   of   some    of  our  measures   of  visual   functioning. 
Obviously,    this   is   not   news   to   most    of  you.      It    is    fairly 
common  knowledge    that   one    can  measure   quite    different   aspects 
of  visual  skill.      However,    if  some    of  these   measures    are   more 
diagnostic   and  predictive    of   future    functioning  outside    of 
the    clinical   setting,    their   relationships   to   one   another   should 
be   investigated.      Perhaps    some    types    of  patient    data   we    can 
provide   to  other   service   professionals   are   more   valuable    than 
others. 

Over  and   above    this,   there    is    another  aspect    which    I   find 
even  more    interesting.       If  this    differential   "visual  efficiency" 
can   be    identified  and  measured   reliably,    it    should  be   possible 
to    trace    out    some    of  its   origins.      In    certain   instances,   it 
may   be    due    to   the    ability   of  the   patient    or   client    to   marshall 
his    own   resources.      He    may   do  this   without   or   in   spite    of   the 
efforts    of   the    clinician.      On   the    other  hand,    it   may   be 
attributable   to    certain  aspects    of  the    restoration   procedure 
the   patient    received.      Thus,    it   may   be    due    to  the    skill    of  the 
clinician.      If   this    is    true,    the   elements    of  care   which   can 
be    identified   to   be   associated  with  thie   type    of   functioning 
should  be    incorporated   into   the    therapeutic  process. 

Now   let   me   begin  now  to   summarize   the   number   of  points 
which   I    and   others    have    been   making.      Some    of   these   are 
primarily   of   a   theoretical  nature ,    others    will   be   more    of 
an   operational   orientation. 


152 


As   a   general  ooint   of  view,    as   a  oosture    if  you  will, 
I   would  urge    that  Dlanning,    regardless    of  its    level   of 
abstractions,    ultimately   be   translated   into  the    language   and 
frame    of   references    of  those   oersons,    be    they   optometrists 
social   workers,    or   rehabilitation  Dersonnel,    who  are    goinp; 
to   use   the    information   that    you  provide. 

Many   ideas  have    been   expressed   within   the   Dast   two 
days.      As    I   have   noted,    they  have    been    involved  with  current 
things.      They  have   not    always   been  exoressed,   however,    in  a 
way   that   they   can   be    used   most    immediately. 

Now  to   some    specific  plans    and   recommendations. 

1.  I   would  urge   that    demonstration   oro.jects   be    under- 
taken  to  examine   all   of  the    resources,    human   and   informational, 
professional   and  interdisciplinary,    in   certain    selected 
communities,    that    can  be   made    available    to   low-vision  patients. 
Then,    in   certain   settings,    show  how  these    resources    can   be 
combined  into  oackages   and  made    available   to  patients.      Then 
carefully  evaluate   and   follow-up    a  number  of   these    results 
translated   into  the    language    of   the   professionals   who  will 

use   them. 

2.  I  would  urge   that   a   systematic    study   of  the   effective 
ootometrlc   clinician   be    carried   out.      My   company  is    currently 
carrying  out   such   a  performance    study,    with    four  special  areas 
in   medicine. 

The   purpose    of  this    research,    would  be   to   identify   and 
isolate    clinical   scales,    which   can   be    shown  to  be    related  to 
the    overall    rehabilitation   of  the    low-vision   patient;    rehab- 
ilitation  again  being  expressed  in  a  number  of  significant 
areas   of   life    function. 

3.  Review  these    findings,    with  an  eye    toward   the 
imolications   toward   incorporation   into  the    curriculum  of 
the    schools   of  optometry.      If  certain   clinical   skills   can  be 
shown   to  be    related  to  effective    clinical  performance    in 
optometry,   then   they   have    a   valid  place   in  the    curriculum  of 
the    schools   teaching  the   profession. 

Speaking  more    generally  now, 

*».      Develop    a  rationale   along  the    lines   Doctor 
Riviere   has    already  started  for  generating  a   system  of 
describing  behavioral   findings    in   a  number  of  different 


15  3 


that   the    vision    loss    of  the   patient   can   be   exoressed 


5.  Alone;  the  lines  of  ray  first  point,  we  must  develoo 
a  better  understanding;  of  the  role  of  perceotion.  In  other 
words,  we  must  know  more  about  the  contribution  the  oatient 
himself  makes   in   coping  with   his    degraded  visual    status. 

This   process    of  perception    is   a   reinforcing  one.      If 
you   are    e;oing  to   change   his    resources,    you  have    got    to 
interrupt   the    way   he    brings   them  to   bear.      This   process 
of  perception   is   a   learnable   phenomenon   and  changes   in   this 
perception   and  changes   in   this    level   of   functions,    have    got 
to  be    described  in   terms   of  intermediate    sequence,    so  that 
every   step   of  the    way  the   patient's   progress   can   be    described. 
This    cannot   initially   be    in  terms    of  the   total   outcome,    total 
rehabilitation,    but    all   along  the    line,   each  ohase    of   operation, 
and   their  relationship   to    one    another   should   be   established. 


McLean,    Virginia 


15^ 


RESEARCH,    DEVELOPHE'IT    A 'ID    EVALUATION 
OF   SENSORY    AIDS    FOR  THE    BLIND 

John    '<.    Dupress* 

The    first    attempt    to   construct   a    sensory    aid   for   the   blind, 
which   would  oermit    access   to   the    printed   word,    was   made    by 
Professor  Fournier   D'Albe    of  Cambridge    University    (England) 
around   1912.      This    device,    called   the    Optophone,    utilizes   a 
linear   array   of   six   photo    sensors    which    are    used   to    scan    the 
letter   a^eas    from   left   to    right    in   a    successive    series    of 
narrow   slits.      The   machine    converts    optically-sensed   information 
to   six   tones   which   are    similar  to   those    of  part    of   the    register 
of   a   Hammond  electric    organ.       Improved   models    of   the    optophone 
were    constructed   during  World  War   II    in   England. 

Although   several   hundred  oeoole   have   been   exposed  briefly 
to  training  with   the    ootophone,    and   a   few  have    had   long 
periods   of   training,    only    one   person    in   the    world,    Miss    Mary 
Jameson   of   London,    has   successfully  used   the    device    for   40 
years   to   read  print    and   typewritten   characters.      The    fact 
that   the    optophone    has    found   so    little    acceptance    among   the 
blind   indicates   that   the   human  engineering  oroblems    in 
learning   and   comorehending  the    outout    is    more    important 
than   the    technical   design. 

Further   research    on   other   reading  machines    began    during 
World   War   II.      Most    of   the   work    in    the    United  States   has 
been   done    under  the    sponsorship    of  the    Prosthetic    and   Sensory 
Aids    Division    of   the    Veterans    Administration.       As    a   result    of 
conferences   soonsored   by   the   Veterans   Administration,    and 
the    deliberations   of   an   advisory    committee    to   the   Veterans 
Administration,    reading  machines   have    been  classified   into 
three    categories: 

1.      Direct    Translation   Machine 


This   machine   employs    a   linear   row  of  photo   sensors,    or 
a    flying  spot    scanner,    to  probe    the    area  containing  the   print. 
The   print   area   is    investigated  by   a  succession   of  narrow   slits 
and   the    device    converts   the    optically-sensed   information    to 
auditory    or  tactile    data.      When   there    is   sufficient    black   in 
the    slit   being   investigated,    the    blind  person   hears   a  tone    or 
feels    a  poke    probe    on   the    surface    of  his    finger. 


*Managing  Director,    Sensory   Aids   Evaluation   and   Development 
Center,    M.I.T.,    292    Main   Street,    Cambridge,    Massachusetts      02142 


155 


The    direct   translation   machine   has   the    following  capabilities: 
relatively   simple    to  build,    low   in   cost,    lightweight,    compact, 
portable,    and   able    to  handle    a   wide    variety   of  tyoewriter  and 
orint    fonts.      In    lots    of   1,009    or  more,   these    machines    could  be 
sold   to  blind   individuals    or   organizations    for   $500   to   $1,000 
apiece . 

The    disadvantages    of   the    direct    translation   machine    are   that 
the   human   being  has   to   do   all  the   processing   of   the    data   which, 
in  turn,    requires    a   long  learning  and  adaptation   time   and  the 
reading  rates    are   very   slow   (usually   less   than   10   words   per 
minute    [WPM]).      Special   qualities    of  motivation,    tonal   memory, 
cutaneous   imagery   or  other  individual   attributes   are   necessary. 

The    most    advanced    form   of  the    direct   translation    machine 
is   being  evaluated  now  with   blind   subjects   at   the   American 
Center   for  Research    in  Blindness    and   Rehabilitation    (Newton, 
Massachusetts).      This   project    is    being  soonsored  by   the 
Veterans   Administration.      The   blind   subjects   at    Acribar 
have    achieved   speeds    of  about    5    worn,   in   soite    of  extremely 
good  engineering  design   and  extensive    subject   training. 

2.      Character   or  Letter   Recognition   Devices 

A   much   more    complicated  aporoach   to  the    design   of   reading 
machines    for  the    blind   is    the    letter  or  character  recognition 
machine.      This    machine    contains   enough   internal    logic   to 
enable    the    optically-sensed   information   to   be  *re cognized*1  by 
the    machine.      The    output    from  this   machine    may   be    a   soelled 
letter  originally   spoken  by   a  human   being   and   retrieved   from 
magnetic   storage,    or  a   Braille    symbol    generated  by   a  variety 
of   tactile    displays.      Most    of  the    work   has   already   been    done 
for  the   blind   subject,    so  that  he   need   only  know  how   to   soell 
and   to   make    certain  adjustments    in  the   machine. 

The   Veterans   Administration   is    sponsoring  a  project    on 
letter   recognition   machines    at   the    Mauch   Laboratories,    Dayton, 
Ohio.      Researchers   at    Mauch   hope    for   reading  speeds   in  excess 
of   60   wpm,   with  a  potential   too    limit    of   120   worn. 

Advance    research   also   is    underway    in   the    sensory   aids 
group    of   the    Research   Laboratory    of  Electronics    at   M.I.T. 
Here,    the    computer  is    being  used   to   simulate   the    functioning 
of  parts   of   a   reading  machine.      Through  the   use    of  ingeniously 
contrived  algorithms    or  coded   letter   feature    data,    it    is 
theoretically  possible    to   build   a   character   recognition 
machine    for   $3,000   to    $5,000,   which    is   better  than   97  per- 
cent   correct   and   can    operate    at    speeds   in  excess   of   100   worn. 


156 


The   principal   advantage   to   the    letter   recognition   machine 
is   that    it    requires   no  new   learning   on  the   part   of  the   blind 
subject    and   adaptation   and   training  time    is   minimal.      Although 
not   as    lightweight    and   compact   as   the    direct   translation 
machine,    the    letter  recognition   machine    with  miniaturized 
circuitry   orobably   would  be    as   large   as   a   standard  electric 
typewriter.      In    lots    of   1,000,   the   M.I.T.    or  Mauch   machines 
orobably    could  be   made    available   at    a   cost    of   $3,000   to 
$5,000. 

3.      Word   Reading  Machines 

There    is    a  Veterans   Administration   sponsored  project 
at    the    Haskins    Laboratories    (Mew   York)    which   uses    a  complex 
machine    to   read-out   teletyoesetter  tape   and   retrieve   words 
spoken   by    a  human   being  and   stored   in   a   magnetic    memory. 
Such   a   machine    is    complex   and  expensive   and   is   intended 
for  a   central   processing   facility    only.      The    cost   would 
exceed   $50,000,   even   if  a  number   of   them  were    constructed. 

The   main   advantage    to   the    word  machine    is    that   the   data 
is   presented  to   the    blind  person   a   word  at   a   time,    similar 
to   the    way   sighted   readers    convert    the   orinted   book   to 
an   audible    form   for  the   blind.      Although   the   Haskins   machine 
does   not   work    fast    in   real-time    (less    than   20   worn),    it    can 
go   on   working  24   hours    a   day.      The    information    is    stored   on 
magnetic   tape    which   can  be   played   later  at    a   word   rate    of 
at    least    102    worn.      With  electronic   time    compression,    the 
final   output    could  be   as    high   as    300   to  500   worn. 

The   practicality   of  the    word    reading  machine    depends 
upon   efficient   handling   of  compositor's   taoes    and   the    acceot- 
ance    of   an   audible    output    which    does  not   have    the    inflections 
or   other  personal   qualities    of   an   actual   reader. 

Since   none    of   the    above-mentioned   reading  machines 
are    in   general   use,    blind  people    must    resort    to   the   alter- 
native   methods    of  3raille    and   sound   recording  media. 

Braille 


There    is    a   research   and   develooment    program  underway 
in   the    Mechanical   Engineering  Department    at    M.I.T.    to   provide 
more   Braille    material   by   means   of   various   Braille    belt   and 
line-at-a-time   Braille    disolays,    a  high-soeed   Braille   embosser, 
and  computer   programs    to   convert    compositor's    tapes*to    Grade    II 
Braille.      The    instrumentation   and   programming  have    been,    and 

*Tapes   used   in  the   publishing   industry   to   set   type,    which 
represent   a    form  more   easily  handled   by   machines    than   orinted 
characters. 


15  7 


are    bain?;,    designed  to  orovide   access    to   a  great    many   more 
books   which   are    stored   on   typesetting  tape. 

Computer  programming  to   convert   teletypesetter  tape 
to   Braille    is   nearing  the    feasibility   stage.      A   monotype 
reader  is   being  designed   so  that   text   books   stored   on 
monotype   tape    can   be    read   into   the    computer   for   conversion 
into  Braille.      Computer  programming  will   permit    almost 
complete   automation   of   comoositor's    tapes   to  Braille    con- 
version,   with   a   minimum   of  human    intervention,    by   means    of 
an   edit    function   which   is    being  built    into   the    computer 
program. 

The   high-soeed  embosser   represents    a  oossible    small 
scale   duplicating   facility    for  3raille.      In    the    area   of 
Braille,    this    unit    is    the   equivalent   of  the   electric   tyoe- 
writer   for  print.      The   embosser  operates   at    speeds   as   high 
as    16   cells   per  second,    can   be    fed   from   continuous    rolls 
of  paper,    and   will    ooerate   with   a   variety   of  electrical 
signals    from  punched  paper  tape    readers    and  other  input 
sources.      Another  example    of   an   application    for  the 
embosser  is    its   installation    in    a  console    at   a   research 
computer   facility  where   a   blind   researcher   is    able    to 
read-out   the    information    from   the    computer.      It   is   hoped 
that   the   embosser  will   be    useful   in   other   computer   facilities, 
since   there    is    an    increasing  trend   in   training  and  employing 
blind  programmers. 

Braille    displays   are    intended  to    read-out   compact    and 
inexpensive    storage    media    for  3raille    other  than   the    actual 
embossed  page.      These    storage    media   could   consist    of  punched 
paper  tapes,   magnetic   tape    recordings   or  optical   storage. 

To    implement    the   high-speed   duplication   of   Braille, 
the    Honeywell   Corporation   has   converted   a  Honeywell   H222 
computer  printer  which   generates    ^31    lines    of  3raille   per 
minute.      Although  this    converted  printer  is   Dotentially 
very   useful,    the    rate    at    which    it    operates    restricts   its 
use    to   one    or  more    central   facilities   where   a   great    quantity 
of  Braille   must   be   produced   rapidly. 

S  oun d  _Re  c  o  rd in  g  Me  di  a 

Sound    recording  media   are    another  alternative   to   reading 
machines.      In   this    case,    a   sighted  human    reads   printed  material 
into   a   tape    recorder  and  the    tape    recordings    are    duplicated 
and/or  serve    as    masters    for   discs   which   are,    in   turn,    distributed 
to   the   blind.      The   principal    research   and   development   projects 
are    sponsored  by   the    Library   of   Congress    in  the    United  States 
and  by   the    Royal   national   Institute    for  the    Blind   in  England. 


158 


Both   projects   employ   cartridges    or  casettes   which   protect 
the    tape    from   damage   and   facilitate   tape   handling  by   the 
elderly   or  multiply   handicapoed.      The    tape   and    its    container 
weigh   less   than    one   pound   for  an   entire    recorded  book. 

Time    compressed   speech   is   an   important    development 
in   sound   recording   media,    which   is   made   possible   by   a 
computer  or  electronic   apparatus   such   as    the   Tempo 
Regulator,    the    Fairbanks    or  the    Varivox.      The   normal   read- 
ing  rate    of   175   worn  can   be   increased  to  more    than   275    worn 
for  extended  periods,   and   to  more    than    475    worn  for   limited 
amounts    of  material.      Speeds    as   high   as   995    wpm  have   been 
achieved  during  exoeriments    at   Harvard  University.      Behavioral 
research   on   time    comoressed   speech    conducted  at    the    University 
of   Louisville,    Harvard   University,    The    American   Institute    for 
Research,    and  the    Air  Force    indicates    that    speeds    of  275    wpm 
are   entirely    feasible   and   speeds   in   excess    of  4 75    are   practical 
for  short   periods   or  for  scanning. 

Research  on  mobility   aids    to  be   used  as   a   supplement 
to    the    cane    or  dog   began   during  World   War  II.      At   that   time, 
a  number   of  ultrasonic   and   sonic    devices   were    constructed 
as   part    of  a   research   urogram   sponsored  by   the    Office    of 
Scientific   Research   and  Development.      During  the   past   twnety 
years,   a   wide    variety   of  ultrasonic,    sonic,    ambient    light, 
infro-red   light   and,    more    recently,    laser   or   laser-like 
devices   have    been   constructed. 

Developments    in   the    aero-space,    military   and   data 
processing   fields   have    greatly   facilitated   mobility   aids 
research.      Rechargeable   batteries,   transistors,    integrated 
circuitry,   high-efficiency   short    wave-length   transducers, 
and   a  number   of  new   auditory   and  cutaneous    displays    have   been 
utilized   in   building  devices   which,    in   many   cases,   weigh. less 
than    one   pound. 

Among  the   potentially   useful   devices   now   receiving 
extensive   evaluation   is    the   narrow-beam  ultrasonic   mobility 
aid   developed  by   Dr.    Leslie   Kay,    formerly   of  Birmingham 
University    (England).      The   Xay    device    operates   with    frequency 
modulated  ultrasonic  energy  similar  to  the    function   of  the 
bat's   sonar.      It    is    hand-held   and   is    capable    of  detecting 
small   objects    at    distances   up   to   twenty   feet,   while    at   the 
same   time   providing  some    additional   data  concerning  the 
surfaces   and   geometry   of  an   object.      The    Russell   device, 
develooed   by   Mr.    Lindsay   Russell   of   Cambridge,   Massachusetts, 
is    a  pulsed   ultrasonic   unit   which   weighs    less    than  a  pound 
and   can   be    fitten    into   a  jacket    pocket.      This    device    is    in- 
tended to   search   the    area  through   which  the   head  and 
shoulders    of  the    subject   will  pass    (not   exolored  by   the 
cane),    at    distances    up   to   six   feet    ahead.      A   third  device 
is    a    long   cane    fitted  with   three    laser-like    sensors    (gallium 
arsenide).      This   project   is   being   carried   out   at    3ionic 


159 


Instruments,    Inc.,   Bala  Cynwyd,    Pennsylvania.      One    sensor 
provides   early  warning   of  terrain   changes,    the    second 
detects   objects   up    to   20    feet    away,    and   the    third  alerts 
the    user  to   obstacles    in   the    area   of  the   head  and   shoulders. 

If  the    three    mobility   devices   mentioned   above,    as   well 
as   others   not    mentioned,    are    to  contribute    significantly   to 
mobility,    they   will   require    more   extensive   use   by   the   blind, 
design   modifications   based  upon   evaluations,    and   the    develop- 
ment   of  soecial   training  procedures    for  blind   subjects.      The 
role    of  mobility    devices   will  become   more    important  as   the 
trend   towards   more    travel   at    all  age    levels   continues    to 
increase  . 

The    instrumentation   mentioned  previously   is   particularly 
relevant   to   blind  persons   with    little    or  no   useful   vision, 
or  to  those   who   are   totally  blind.      However,    there  has  been 
a   limited  amount    of   research   and   development    for  the   partially 
sighted.      The    first   project    for  this    group   specifically   de- 
signed to   give    them   greater  access    to  printed   matter  was 
carried  out   at    Dartmouth   College    and  Perkins   School   for  the 
Blind   during  World  War  II,    under  the    sponsorship    df  the 
Office    of  Scientific   Research   and  Development.      Since    that 
time,    a   great    many    low  vision   aids   have   been  developed  by 
ophthalmologists,    optometrists,   physiological  psychologists, 
and  technologists.      Dr.    Louise    Sloan   of   Baltimore   has   issued 
a  most    impressive    compendium  of   these   aids. 

Conspicuously   absent    from  existing   low  vision   aids    are 
devices   which   could   assist   in  the    mobility   of  the   partially 
sighted.      There    is    a   wealth   of  valuable    data   concerning 
successful   applications    of   low   vision   aids    for   reading,    but 
there   has    been   very   little   experience    with   mobility   aids   under 
the    complex  and   dynamic   conditions   encountered   in  every   day 
pedestrian   travel.      Optometrists,   ophthalmologists    and 
rehabilitation   specialists    for  the   partially  sighted  must 
undertake   applied   research   and   field  testing  of   low  vision 
aids   which  will  permit    mobility    for  those   with    less   than 
20/200    vision. 

The   elderly   comprise   the    majority   of   our  blind  and  partially- 
sighted  population.      Deterioration   of  the    remaining  sensory 
channels   and  processing   of  information   by   the   brain  come   with 
aging.      Because    of  the    relative  poverty   of   this    group,    they    are 
unable   to  take   advantage   of  even   inexpensive   sensory   aids. 

In  England,    a   survey   of   the   needs    of  the   blind  is   under- 
way  which,    for  the    first   time    in   the   history   of  the    field,    will 
provide    some    definitive    data   on   the    real  needs,   oroblems, 


160 


questions   and   suggestions   of  the   blind  population.      When   we 
really   know  what    chances    occur  with   blindness    and  aging,    then 
we    can   olan    for  the   enhancement    of   functioning   or   caoability 
of  the   blind   through   the    use    of   technological   aids. 

Each    individual   mobility    device    is    intended    to  helo    in 
the    solution   of   one    or  more    of   the    following  sub-tasks: 
(1)    early   detection    and/or   recognition   of   objects    in   the 
intended   travel   oath;    (2)    detection   and/or   recognition   of 
objects    for   orientation    and   navigation    ourooses;    (3)    early 
warning  of  terrain   chances    (step-ups    and   step-downs);    and 
(4)    three-dimensional   environmental    sensing   beyond   the 
reach    of  the   blind  oerson's   hand   or   cane.      'lone    of  the 
devices    is    caoable    of   replacing  the    cane    or  the    dog,    but 
some    of   the    devices    may    be    very   useful    suoplements   to   the 
cane    or  dog  after  aporopriate    training. 

The    comouter   is    becoming   very   important    in   the    lives 
of   the   blind,    and   the    following  are   a    few   important 
apolications :       (1)    new   careers    in   data   processing  are 
opening  up    for  the    blind  because    of  newly  established 
training  programs;    (2)    the    American   Printing  House    for  the 
31ind  now   is    able    to  translate    English   into   Grade    II 
English   Braille;    (3)    a    Honeywell   Corporation    computer  line 
printer  has    been  modified  to  produce   high   quality   3raille 
at    431   lines   oer  minute;    (4)    M.I.T.    now   is    able   to   simulate 
the    functioning   of   reading  machines,    mobility   devices    and 
the   environment   through   which    a  blind  traveller  oasses 
while    using  a   device;    (5)    data   obtained    from  the   evaluation 
of  mobility   devices   can   be   processed   more    accurately   and 
faster  than  by   human    observers;    (6)    compositor's    tapes    are 
being   converted   to   Grade    II    Braille    and   later  may   be    used 
for  generating   synthetic   speech;    and    (7)    time    comoression 
of  soeech,    at   rates    as   high    as    1,000    worn   for  certain 
material,    will   improve   the    reading  and   comprehension    of 
speech  by   the   blind. 

It    is    anticipated  that   applications    for  the    comouter 
will   increase    markedly   in  the   near    future. 

The    conceot    of  employing   an   evaluation   to   determine 
the   worth   of  a    given  sensory   aid  evolved   at    the    Haskins 
Laboratories    during  World  War  II.      Good  evaluations   make 
this    determination    objectively    and  accurately,    provide    guide 
lines    for   improvement    of   the    device,    and  add  to   the    body   of 
scientific   knowledge    concerning   blind   reading   and   mobility. 

Evaluations    are    penerally   undertaken   by   a   team   comprised 
of  behavioral   scientists,    technologists   and   rehabilitation 
soecialists    in   work    for   the   blind,    in    order   to  help   determine 


161 


the    funding  policies   of   organizations.      However,    they   are 
more   useful   to   researchers   who   look  upon  them  as   important 
sources    of  information    for  the    design   of  better   sensory   aids, 
In   the    past,    each   evaluation   has   been    initiated  by   a  new 
team,    but    the    current    trend   is   toward  the   establishment    of 
permanent   evaluation    facilities.      Now,   evaluations   are 
initiated   routinely   whenever  a   reading  machine    or  mobility 
device   has   been   comoleted   in   the    laboratory  phase. 

The    totally   blind  serve    as   subjects,    since   most    devices 
are    intended   for  people    with  no    useful   vision.      In   the    case 
of  mobility   aids,    field   testing  in   real   life    situations   is 
more    important   than    tests    conducted   under  controlled 
laboratory   conditions. 

In   addition   to  evaluation,    a   survey   should  be   donducted 
to  determine    the    real  effectiveness   of  sensory    aids   used  by 
the   blind  over  a    long  period  of   time.      This   is   particularly 
important    in   the    case    of   low  vision   mobility   aids    designed 
for   the   partially   sighted. 


In   the    final   analysis,    the   proof   of   the    worth   of  i 
given   sensory   aid   is    the    regularity   with   which    a  blind 
person   uses   it    in   successfully   solving  the   problems 


1.  Proceedings  ,    Rotterdam  Mobility   Conference.      American 
Foundation    for  the    Blind,   Mew  York,    May,    1965. 

2.  Proceedings .    International   Congress   on   Technology   and   Blind- 
ness.     American   Foundation    for  the    31ind,   New  York, 

Vol.    I,    II    and  III,    1963. 

3.  Reading  Machine    Conferences    1   through   6,    Veterans   Adminis- 
tration,   Prosthetics   and   Sensory   Aids    Division,    1951-1966. 

4.  Dr.  Louise  Sloan  and  Maria  D.  Jablonski,  "Reading  Aids 
for  the  Partially  Blind,"  reorint  from  AMA  Archives  of 
Ophthalmology,   Vol.    62,    p.    465-484,    September,    1959. 

5.  Proceedings ,    International   Conference    on   Sensory   Devices 
for  the   Blind,    St.    Dunstan's,    London,    England,    June    13-17, 
1966    (to  be   published). 


162 


THE    WELFARE    ADMINISTRATION 
U.    S._   DEPARTMENT   OF   HEALTH,    EDUCATION    AND   WELFARE 

Joseph  Meyers* 

I   am  with  Welfare   Administration,    Department    of     Health, 
Education  and  Welfare.      This   is    a   separate   unit   within   the 
Department.      Very   briefly,    let    me   explain  what   we    do  in 
Welfare   Administration.      We   are    concerned  with   that   often 
maligned  and  very   often   misunderstood   subject,   public 
welfare.      Specifically,    the  programs  with   which   we    deal, 
are    the   public   assistance   programs  which  provide    financial 
assistance,    social   services,    and  medical  assistance    for 
needy   and  near-needy  individuals. 

We   are   also   concerned  with   all  problems   affecting 
children  in  the    area   of  health   and  welfare   through  the 
Children's   Bureau  which   is   part   of   our  organization.      We 
have   a   separate    organizational  unit   which   deals  extensively 
with  problems   in  prevention  and  control   of  Juvenile    delinquency. 

To   list   a   few   of  the   areas   where    our  programs  orovide 

aid  and   services   to  people    of   low  vision:      first,  there   are 

the    comprehensive    categorical  assistance   programs  which 
provide    income   and   services   to  needy  individuals. 

Through  the    Children's   Bureau  we  have  programs    for 
crippled  children,   maternal  and  child  health,   which  I 
think  were   mentioned   to   you  earlier  during  your  program 
by   some    of   the    other  people    from  our   organization.      In 
addition,    social   services   are   provided  to  children  and   families. 
We    also  have   a   very    large   new  medical   care   program  under  title 
19   of  the   1965   amendments   of  the   Social  Security  Act,   about 
which   Miss    Butts   told  you   last  night. 

Another  thing  I   think  we    can   do  which  ties    in   with   what 
Dr.    Teare    mentioned  to  you   is   to   supply   demonstration 
possibilities.      We   have   quite   a   few   areas   in  which   funds   are 
available   to   state    and   local   communities   for  demonstrations, 
which   could  be   used  to  mount   a  project;   try   to   demonstrate 
or  experiment   with   ways    of  bringing  social   services   and 
medical   care   to  people    of   low  vision.      I   think   another  area 
where   we  have    so   much   in   common   would  be    the    0E0   Program  that 
Dr.    Hunter  mentioned.      This   is    in  the   whole   area   of  bringing 
together   and   involving  the    community  total   in  bringing  services 
to   individuals. 

*Deputy  Commissioner  of  Welfare,    Welfare   Administration, 
U.    S.    Department    of  Health,   Education   and  Welfare. 


163 


This    is   a   big  gap.      There    are   not   enough   services; 
they   are    sootty    in    location    and  quite    often    the    ereat 
range    and  battery    of   services   that   are    available   are   not 
prooerly   united.      There    is   much   selfishness,    and   it   is   a 
big  job   trying   to   get    oeople   to  work   together.      All   of 
the    resources   are   needed,    both   voluntary    and  Dublic. 
Research?      We    don't   do  enough   of   it!      You  have   heard 
a   lot    about    that    in    other  areas,   but   we    don't   do  the 
necessary   research   in    this    social  welfare    area  either. 
We   need  to   develoo    our   research   capability,    trying  to 
find   answers   to   social  problems.      We    must    learn    to 
innovate    a    little    more;    to    find  new  methods    to   simplify 
our  procedures. 

The    big  .job,    of  course — the    one    we    are    finding   all   of 
the    time    in   all   of   our  areas,    and   that   we   have    to   solve,    is 
the    manpower   shortage   problem.      Mot    only   in   the    medical 
field  and  the   paramedical    field,    but    also   in   the    social 
and  economic    fields   we   have    real  problems   about    manoower. 

I  have  seen  estimates  that  in  public  welfare  alone, 
by  1970,  there  will  be  a  need  for  a  hundred  thousand  new 
social   workers — just    in   public    welfare! 

Well,    we   haven't    got    the    schools   to   turn   them  out    so 
we   have   to   do   something   really   dramatic   in   this   area. 
Training,    better  utilization,    simplification   of  orocedures  — 
all   of  these   things   are    sorely   needed. 

In    short,    I    think   the    message    I   would   like   to  bring   to 
you   is    that    for  public   welfare    and  as   public   welfare,    we 
have   a   vital   interest    in   being  able    to   improve    services 
generally.      There    is,    in   every    county   in   the    United   States, 
and   there    are    about    thirty-three    hundred   of   them,    a  public 
welfare   department.      This    is   a    force    which   is   uniformally 
pervasive   throughout    the    United  States   and  it   can   be   a 
unifying   force    in   trying   to   bring  together  these    varieties   of 
services   so  that   they  can   be   unified  and  all  appropriately 
utilized. 


Washington,    D.    C. 


164 


QUESTION    DIRECTED   TO  MR.    MEYERS:      Could   you   comment    on 
the   provision    for  visual   care    in   title    ten   of   the   Elementary 
and  Secondary   Schools   Act?      Is    it    available    for  optometrists 
and  ophthalmologists? 


MR.    MEYERS:      If  you   refer  to   Title    Ten  of   the   Elementary 
and  Secondary   Act,    I   am  not    familiar  with   it.      If   it   is 
by   any   chance   Title    Ten    of   the    Social   Security   Act,    which 
provides    for   assistance   and   medical    services   to   blind 
individuals,    I   can't    comment    on   that,    but   I    really   don't 
know  enough  about   the    Elementary  and   Secondary    Act   to 
comment   on    it. 

There    is    a  provision    in   the    Social  'Security   Act,    which 
provides    that    in   determining  blindness   a   state   must  have   an 
examination   as   to   blindness  which   can   be    done   either  by    a 
physician   skilled   in   the    diseases    of   the   eyes    or  by  an 
optometrist — and  the    choice    must   be   the    choice    of   the 
individual  applying  for  the   assistance. 


165 


VOLUNTARY  COMMUNITY  ACTI ON 

— ------  ---  -  .     |     -  | 

Lee    Holder* 


I   think   I   would   like   to  shift   the    conference    ^ears  here 
a   little   bit    and  tell  you  about   one   effort   at   melding  this 
action   research   which   we   have   been   talking  about — the    meld- 
ing of   social   research   with   community  action   throughout   the 
United   States    In   a   voluntary  effort. 

I   would   also   like    to   distinguish  the   Community   Action 
Studies    Project    with   which   I   have    been   working   from  that 
of  which   Dr.    Hunter  has   been    talking.      The    National  Commission 
on   Community  Health  Services   was   set   up   as   an   independent, 
temporary    commission,    funded  primarily  through  Kellogg  Foundation 
with   some    Public    Health   Service    assistance    and   other   funds. 

Our  charge    in   the    Community   Action   Studies   Project   oart 
was   to   identify   and  analyze    some    of  the   princioles    of 
community   action,   particularly  those    related  to   improving 
and/or  maintaining  health   services.      This   was   a   voluntary 
effort,    as   I   said,    in  the    interest    of  time,    I  would   like 
to   read  a   statement   about   the    Commission's   work. 

One    of  the   most    significant    recommendations   evolving 
from  the   National   Commission    on   Community   Health   Services, 
as   a   result    of  its   four-year  study,    has   been   one    that   urges 
communities  throughout    the    country   to   intensify    cooperative 
health  planning  efforts.      We    call   this   process    "action- 
planning"  . 

My   purpose    is    to   discuss    the    findings    and   imolications 
of  the   National   Commission   that    relate   to  planning   for  the 
future   to   imorove    community  programs   and  aoply   to  orograms 
for  the    visually   limited. 

Let    us    first   consider  three    concepts   which  are    fundamental 
to  the    subject: 

1.      A   concept    of   community  _he alt h   services--No   longer  can 
we   think   of   community  health  "as   being   in  the   exclusive    domain 
of   one    group    or  agency.      Community  health  encompasses  personal 
and  environmental  health   services    and  the    many  elements   necessary 
for  delivery   of  health   services    to  people. 


*Director,    Community   Action   Studies    Project,    National 
Commission   on   Community   Health   Services. 


166 


Ve    nust    recognize   the    many   different   and   varied   roles, 
resoonsibilities,    and   functions   incidental   to   providing 
comorehensive   community  health    services   to   insure    that 
services   will   be    available,    accessible,    acceptable   to   the 
consumer  needs.      Attaining  the    goal   of  comprehensive 
community   health    services    requires    dynamic    inter-action 
between   and  among  many    groups   that   take   part    in   delivering 
health  services — governmental   agencies,    voluntary  health 
and   welfare    agencies,   hosoitals,    schools,    industries,    civic 
leadership    groups,   and    others. 

Of  course    we   must   not    forget   the   key   role    of   indi- 
viduals  in   the    concept.      One    of   our  health  education    goals 
is   to   stimulate    the    individual   to   seek    resoonsibility   for 
his   own  health. 

Private   practitioners   of  the   health   and  medical    sciences 
comprise   the    cornerstone    of   health    services    in   our   country — 
the    physicians,    dentists,   pharmacists,    optometrists,   and 
others. 

Although   we    recognize    their   roles   as   being   fundamental, 
our  primary   interest   within    the    Commission   has    been    to 
concentrate    on   those    services   that    are   organized   and   carried 
out    on   a   community-wide    basis    rather  than    that   of  the    one-to- 
one    relationship    of  private   oractice. 

2.      A   concept    of  health   community — In   the   past   we  have 
too   often   defined   our  community   as   our  neighborhood,    village, 
city   or   county— usually   an   area   contained   within   a  circum- 
scribed political   .jurisdictional   boundary.       \fe    find,    however, 
not    at    all   to   our    surprise,    that   health   matters    are   no 
respectors   of   these    traditional   boundaries. 

The  health  problem-shed  and  health  market  area  conceots 
better  describe  areas  in  which  we  must  work  to  solve  health 
oroblems   efficiently  and  effectively. 

</e   might    call   this    kind    of   community   the    "community    of 
solution",    i.e.,    a   health    community  must   encompass    an   a^ea 
large   enough    for  people   within    it   to  have    resources    sufficient 
to   solve    the    problem.      Specific    geograohical   areas   may   be 
different    for  each   oroblem,    for  example,    the    water-shed   may 
be    vastly    different    from  the   hospital   trade   area,    or  a 
number   of   other   communities   of   solution. 

The   ooint    is    this — responsible   people   must   r-e-think 
traditional    ideas    about   their  health   community   boundaries 
and   develoo    the    coordinative   mechanisms   through  which   we   can 
make    the   most   effective   and  efficient   use   of   our  resources   to 
maintain   quality   health   services. 


167 


To   attain  this    goal   will   require    inter-agency   and   inter- 
jurisdictional  agreements,    teamwork   and,    in    short,    action- 
planning. 

3.      A   concept    of  c  omp  re  hens  ivene  s  s — If   there    were    one 
word   which   would   describe   the   work   of  the   National  Commission 
it    might    well   be   the   word   "comprehensive".      We    speak   of 
comprehensive   community  health   services,    or  comprehensive 
community  health  action-planning,    of   comorehensive    care 
for  the    individual. 

A    few   simple   examples   will    serve   to   illustrate    some    of 
the    interrelationships    among  health  problems,    pointing  to 
the   need   for  a   comprehensive   aoproach   to  personal  health  and 
the   necessity   for   all   members    of  the   health   team   to  work 
closely   together   for  the    benefit    of   the   patient. 

The   child  whose   eye   problem  is   discovered  through   a 
visual   screening  program  may   not   have   his    health   problems 
resolved   merely   with  the    fitting   of   glasses;    this    health 
problem  may   have    caused  him  to   fall  behind   in  his    classes 
and   suffer  academically,    resulting  in   emotional   problems    at 
school   and  at   home,    or  there    may  be   a  number   of   other 
physical,    social,    and   mental   problems   connected   with   any 
given  episode    of   illness. 

The    malnourished  child   discovered   in   the    classroom  may 
be    symptomatic    of   larger   family   social  and  economic   problems; 
or  the    dentist    may   discover   signs    of   oral   cancer   in   a   patient 
who   comes   to   his    office    for  dental   work. 

Is    it   not,    therefore,    the    resoonsibility   of   the   person 
who   discovers   these   other  multiple   problems   to   refer  each 
individual   to   those   resources   which   will   attend   to  his 
other  problems? 

We    realize    that    many   practitioners    routinely   refer 
patients,    but   how   often   do   other  health    groups    refer  and 
f.ollow   up?      At    best    it   varies. 

We    cannot   neatly   compartmentalize   health   oroblems   and 
resoonsibilities    into   separate    domains.      We   must    think   of 
health   as   a   community   affair  and   develop   the   kinds   of   relation- 
ships  which   will   helo   us    to   realize    our   goals    for  providing 
quality   services   and   improving  the   health   status    of   the   oeople. 

Within  the    structure    of  the   Mational  Commission,    a  Community 
Action   Studies   Project    was   developed  to   identify   and  analyze 
principles    and  methods   that    facilitate   effective    community 
action   to   imorove   health   services. 


16  8 


In   order  to   do   this,   we   recruited  twenty-one    community 
groups   throughout   the   nation   to  conduct    self-studies    of  their 
own  health   services    and  to  allow  us    to   study  community  action 
processes   in  these   communities    as   they   studied  themselves — 
through   a   social   science    research   technique    called   "process 
analysis" . 

Other   study   activities    in   which   we   engaged   in   CASP 
were:      a   study   of   community   readiness   to  act;    a   retrospective 
analysis    of  some    2,000   previously   conducted  health   studies; 
a   series    of   special   case   studies    of  community   success   ex- 
periences   (focusing  on   the   politics   of   community   health 
planning) . 

Findings    from  all   these   study   activities   point   to   one 
central   imperative — the   process    of  action-planning  within 
communities.      One    of   the   key    factors    distinguished   ready   from 
unready   communities   in   the   presence    of   an   effective   planning 
group    (either   formal   or  informal). 

Results    from  case   studies    of   successful   community   pro- 
grams point   to  outstanding   leadership   and  long,    carefully 
built   traditions   of  planning  as    factors.      Process    analysts 
agree    that    success   in  planning  is    largely   shaped  by   the 
quality   of  community   leaders    that   participate    in   health 
planning  activities. 

Many  professionals  have    traditionally   felt   health  planning 
to   be    a  professional   affair,    but    our  studies    show  quite 
conclusively   that    health   is   a   community   affair — health   issues 
are    intermingled   with  non-health   issues,    such  as    traffic 
problems,    urban   development,    economic    growth,    race    relations 
and  a  number  of   other  community   concerns.      To   achieve    community 
action    in  health   requires   a   collaborative   partnership   between 
health  professionals   and  civic    leaders. 

From  these    studies   has   come    the    concept   of  action-planning 
as   a  process   to  meet   the   need   for  appraisal,    study   and  planning 
geared  to   a   continuous   action  program   for  improvement    of   health 
services. 

Most    important,    it   has    been  emphasized  that    such   action- 
planning  must   be   community   oriented  with   wide   community 
participation.      This    is   because    we    find: 

1.      Mo  two    communities    are   the    same--each   differs    in 
specific   health  problems,    resources,    and    goals.      Action- 
planning,    as    a  process,   must   be    geared   to   a  community   and   its 
people,    taking  "these   differences   into  account   and   dealing  with 
them  in  a   realistic   and   relevant   manner. 


169 


2.  Community   health   action-planning  is    a  orocess    and 
not   a   goal   in   itself,   although   its   potential    for  meaningful 
participation    in   community   citizenship   has    immeasurable 
implications   for  our  way   of   life. 

3.  The   nature    of   today's    society   and   its    complexities 
of  health   and   other   community   services   necessitates   ways   and 
means   for  planning  and   action   not    only   tailored   to  each   community 
situation,    yet    are    in  harmony  with   broader  trends,    and  with 
flexibility  to  adapt   to    further   development    and   change.      We 

must   be   able   continuously   to   adapt    to  technologic   and   social 
change   and   function    within   the    realities    of  the    community,    the 
state,    the   nation,    and   the    world. 

4.  Use    of   the   term   "action-planning"    is   based   on    the 
belief   that  neither  study  nor  planning,    as   such,    is    sufficient 
to  accomplish   community   goals.      Action    is   essential   and  must 
be    stressed  throughout.      Approaches    which    foster  adaptation 

of   general  principles    and  methods    of  action   to   diverse 

community  patterns   must    be   developed.      The    approaches   must 

be    geared:      (a)    to  understand   and   identify   problems; 

(b)    to  establish   appropriate    goals;    (c)    to  utilize    resources; 

(d)    to   influence    attitudes;       (e)    to   resolve   conflicts; 

(f)    to    facilitate    decision-making;      (g)    to   stimulate    action 

and   continued  evaluation. 

Within   this    context,    action-planning   for  community  health 
services   should   be   comprehensive    in    function,    c ommun i t y - w i de 
in   area,   continuous   in  nature,    and   action-oriented. 

What    are    the    implications    for  action-planning   that 
relate    more    specifically   to    community  programs    and   services 
for  the    visually    limited? 

First,    we   must    recognize    that    resources    for   aiding  the 
visually    limited  exist    within   a  number  of  places   in  any   given 
community.      In    addition  to  private   practice,    many    governmental 
and  private   health   agencies  have    a   stake    in  programs;    so   do 
many   civic    groups.      For  example,    in   any   given  community   the 
Lions    Club   will   usually   have    a   vision  program;    the    Rebekah 
Lodge   may   have   an   eye-bank  program;   Vocational   Rehabilitation 
programs   will   exist   as   a   resource;   health  departments,    schools, 
and   other  agencies   will  undoubtedly   provide    services. 

In   order  to  prevent   duplication,    overlap,    or   gaps    in 
service    and  to   identify    goals    for  meeting  needs    for  the 
visually    limited,    a   cooperative,    collaborative,    coordinated 
approach   is   needed--this   we   call   action-planning. 


170 


Vision  needs    and  programs,    however,    do  not   exist    in  a 
vacuum.      They   relate    to   and   are    affected  by   other  health 
needs    and  programs.      One    objective    should  be    to   relate 
orograms    for   visually   limited  to   other   community  health 
activities   and   make    services    for  visually-limited  oeople    a 
recognized  part    of  community  health  programs. 

Persons    interested   in   improving  programs    for  the 
visually    limited   should  not   hesitate   to  participate    in   health 
planning  activities.      One    word   of   advice:       if   there    is    a 
planning   group    in   the    community,    do  not   wait   to   be    invited 
to   join   in   the   work--volunteer  to   serve    as   a   person    interested 
in   oeople    and  their  health,    of  which   eyesight    is   a   vital 
function.      This   is    one   way   in  which   vision  problems   can   be 
brought   to  the    attention   of   others    in   the    community   and   in 
which   support    and  appropriate   programs    can   be    developed. 

It   is    a  way   by   which  eye   health   can   be    related   to   other 
ohysical   and  emotional  problems   and   coordinated   orograms 
can   be   implemented   at   the   community   level.      Schools,    health 
departments,    voluntary    organizations,    hospitals,    service 
clubs,    industry,   and  many   other   groups    can   coordinate    their 
activities    for  the    good   of  visually-limited  oeople   by  working 
and  planning  together  to   identify  needs    and   resources,   establish 
realistic   goals,    and   develop   action-plans    to   achieve    their  own 
self-determined   goals. 

Self-study   is   one   technique    that    will   work  to  accomplish 
action-planning   objectives.      As   a   oart    of  the    Commission's 
work,    CASP    developed   a   orogram  of   self-studies   in   twenty-one 
communities   throughout   the   country.      Self-study   as   a  ohilo- 
soohical   concept   and  an  action    mechanism  for  improving 
health    services   provided   a   setting   for  all   groups    (health 
and   non-health)    to   come   together  to   study    community  health 
programs,    services,    and  needs;    to   set    goals,   to   develop  plans 
to   action,    and  to   act    on   their  plans.      It    provided  an   opportunity 
for   study    groups    to    relate    the    various   parts   of   community 
health  programs   in   a  meaningful   way   and   deal   at   one   time    with 
the    shole — environmental  health    to   personal  health,    in    fact, 
health   problems   with   broader   community  needs.      It   was    a 
chance    for  health   to  become    a   community   affair. 

These    self-studies   orovided   unorecedented  educational 
opportunities    in   improving  health  services   through   developing 
the    recognition    of  needs    and  oroviding  at    the    same   time    an 
action   vehicle    for  develooine   needed  orograms. 


171 


VJhile    the   oarticioating  agencies    and   groups    studied 
broad  problems,   they   also  could  olan  agency    goals    and  uro- 
grams  that    fit   into    the   whole   pattern   of   community  health — 
supplementing  and   complementing  efforts    of   other   groups 
and   reducing   overlap,    fragmentation,    and   duplication. 

Challenges,    opportunities,    and   responsibilities    for 
working  together   cooperatively,    for  developing  new  programs 
to  meet   nev;   or  changing  needs,    for  planning  ahead    for  the 
future    are    with  us   as  never  before. 

We   have   experienced   in  a    lifetime    the   advance    from  the 
Model-T  Ford  to   rocket    flight   to    outer   soace--but   can   we 
rightly   be    accused  of  using   Mode 1-T-tyoe   health   urograms 
for   space    age   health  needs?      Hence,    action-planning   is   no 
longer  a   luxury — it    is   a  necessity   if  we    are    to   solve    the 
problems    that    will   be   with   us    in   the    decades    ahead,      "ie 
must   all   do   our  oart   and   acceot    these    added   resoonsibilities 

We    must   believe    in  health   as   a    community   affair. 


7615    Old  Georgetown   Road 
Bethesda,    Maryland,    20014 


172 


COMMENTS   BY    RESOURCE    PANELIST 
J.    F.    Follmann,    Jr.* 

I   certainly   think,   and   someone    should  have    said  it    long 
before   this,    the    AOA   should  be    greatly   congratulated   on 
this   session   of  planning   for  the    future   because    this    sort    of 
thing  is   not    only   well  needed,    but    such  a   broad   gauge    approach 
as   has   been   taken   here    this   afternoon,    is   extremely   worthwhile. 

I   think   Dr.    Davis'    point    on    the   need   for  what   he    calls, 
the   team  approach,    which   I    supoose   will   mean   more    under- 
standing and  mutual   aporeciation   among   the   professions,    is 
a  very   important   point. 

Those    of  us   in   the    Health   Insurance    field  have    an 
interest    in   all    such    developments    as   have    been    discussed 
here.      We    become    increasingly   frustrated  at   times   when   we 
encounter  absence    of   coooeration    and  mutual   understanding 
on   the   part    of  the    various  professions   in  the   health   care 
field.      I  think   our   lives   would  be    a    lot   easier   if  some   neople 
could   learn   to   talk   with   one    another  more    frequently. 

Dr.    Hunter's    aporoach   to  the    social    aspects   struck  me 
as  extremely   imoortant    because    sometimes    I    get    the    feeling 
that   there    Is   too  much   attemot   to   isolate   health    factors   unto 
themselves,    while    leaving   out   the   many   other   factors   which 
have    bearing   on   this. 

The    very  problem  of  a    low  degree    of  education,    which   is 
much  more   orevalent    in    our  United   States   population  than   we 
choose   to  think,    is    of  basic   imoortance.      The    more   the    facts 
of   life    come    to   the    surface,    the   more    one    comes   to   recognize 
that   where    general  education    levels   are    low,   there    is    a 
general   absence    of  needed  health   care.      To  those    of  us   in 
the   health   insurance    field,   where    usually/  the   equation 
rapidly   becomes  economic,    this    is   a   matter   of   some    interest 
because   these    same   people   are   the   people   who   do  not  have 
health   insurance    protection.      This    is    a  matter  which   interests 
us   very  much  because   the    whole    spectrum   of   social,    cultural, 
and  educational    factors   in   life   have    such   a   close    relationship 
to  health,    to   the    obtaining  of  needed   care,    and   to  the   meanings 
of   financing  that   care. 


^Director  of  Information   and   Research,    Health   Insurance    Asso- 
ciation   of   America,    750  Third   Avenue,    New  York,   New  York      10017. 


173 


Dr.    Teare    certainly   soelled   out   the    future    for  many   of 
us.      Those    of  us   in   the    research,    who  are    usually  pretty 
good  at   spelling  out    long-range    future    goals   would  hope 
that   no   one    would   deny   that    research   always   plays   an   im- 
portant   role. 

QUESTION  DIRECTED  TO  MR.  FOLLMAMN:  It  has  been  suggested 
that  insurance  oractices  may  inhibit  the  hiring  of  handicapoed 
persons.      Would  you  please    comment? 

MR.    POLLMANN :      This    is    a   common   point   which   turns   up   every 

now  and  then.      I   don't  know,    well,    I   guess   maybe    I  do  know, 

where    it    comes    from — but   in   the   process    of  writing  group 

insurance,    the    insurance    company  knows   practically  nothing 

about   the   peoole   they   are    covering,    they  know  what  occupation 

they   are   engaged  in,    but   they   have   no    idea   whether  there   are 
or  are   not   oresent   handicaoped  people. 

So,    this    factor  does  not   enter  into   the   health   insurance 
oicture    in    the    slightest.      I   would  exoect    that   there    can   be 
an  occasional  emoloyer  who  has    some    concern   about   hiring  a 
handicapped  person,    and  puts   the   blame    off  onto   his   other 
costs,    including   his   insurance    cost. 

I   suppose    there    can   be,    at   times,    instances   where    labor 
unions,    through   a   concern   of  seniority   rights   or  whatever, 
may  have   a   concern   about   employing  handicapoed  peoole   and 
can   put   the   blame    off  onto   the    cost   of  health  and  welfare 
programs.      But    I   don't    see   how  the    grading  methods   employed 
by   insurance    companies   could  affect    the   employment   of 
handicaoped  peoole   at   all. 


172* 


QUESTION   DIRECTED  TO   MR.    DUPRSSS    AND  DR.    TEARE:       Both 
of  you  have    referred  to   the   need  for  new   research  of  an  inter- 
disciplinary nature.      It   would   seem  that   new   research  models 
are   needed.      Will   you  please   comment   on  this? 


MR.    DUPRESS:      There    is    only   one    sensible    approach   to 
evaluating,    or  determining  the   effectiveness   of,    complicated 
sensory   aids    designed   for  the   reading  and  mobility  problems 
of  the   blind.      The    team  approach   is   absolutely  necessary; 
the   team  should   consist  of  technologists    (engineers   and/or 
physicists),    behavioral   scientists    (sensory   and  experimental 
psychologists),    and   rehabilitation   specialists   who  are   aware 
of  the    details   of  problems  encountered  by  blind  people   in 
their  day-to-day   lives. 

The   difficulty  with   experiments   designed  to   measure    the 
worth   of  a   sensory  aid   is   that   they   are    generally   conducted 
under  extremely   simple    laboratory   controlled  conditions. 
They   seldom  resemble   what    goes    on   in   real   life,    and  this 
is   particularly   true    of  mobility   rather  than   reading  devices. 
Reading  devices   generally   involve   measurements   of  comprehension, 
training  where   necessary,    the   amount   of   learning  required  on 
the   part    of  a  blind  subject,    and  some    other   factors.      Mobility, 
however,    involves    real   life    situations   which   rarely   can  be 
simulated  in   the    laboratory. 

In   the   measurement    of  mobility    devices,   it    is   necessary 
to   reduce   the   use    of,    or  eliminate   altogether,    human   observers. 
Therefore,    the   experimental   design  should  employ  tracking 
instrumentation  to  monitor  the   movements    of  the   blind  sub- 
ject   as   he   uses    a  given   mobility   device,    computers    to   analyze 
the    data,    and   film  and  sound  recordings   to   capture   information 
for   future   analysis. 

The   use    of  models   relating  to  experimental   design   or  the 
origin   of  theories   is   not   as    straight-forward,    in  the   case   of 
sensory   aids   for  the  blind,    as   one    might  think.      We   know  so 
little   about   human  mobility — sighted   or  blind — that   it  is 
difficult    to   construct   useful   models.      If  we   are    trying  to 
develop   a   sensory   aid  to  present   even  a  highly    limited   form 
of  vision   through   some    remaining  sensory   channels   or  directly 
into   the   brain,    the   existing  models   are    of  little   assistance. 
The    types    of  models  we    can   realistically   think   of   at   the 
present    time    are    what    one    might   call  block   diagrams    of  the 
tasks   or  bus-tasks   which   are    involved   in   reading   or  mobility. 
They>  are   useful   when  accompanied  by  enough  descriptive    data 
to   illustrate   the  nature   of  the  problems  to   scientists  not 
in   the    sensory   deprivation   field. 


175 


FURTHER  ANSWER   3Y   DR.    TEARS:       Let   me    add   a    few   comments. 
The    implication   of   some   of  the    comments   he    made    were    that 
there    were    already   in   existence    a  number   of   models   which   can 
be    used   to   describe   human   behavior,    and   I   have    to   agree    with 
this. 

Some   of   the    forms    of   human   behavior  you   want   to   study 
in  their   real   conditions,    separated   from  the   oure    laboratory 
environment,    begins    to   break   down   because    the    models    aren't 
complete   enough   or   our  mathematics   isn't   sophisticated 
enough  to   handle    what   are    known   to   be    many    linear   functions 
in  very,    very   complicated  combinations. 

The   most    important    limitation,    I   think,    from  the    stand- 
ooint    of  psychology    at    the   present   time,    despite    our  abilities 
to    speak   and   verbalize    and   use   big  words,    is    that   we   haven't 
really   been   able    to  measure   the    things    that    seem  to   be    of 
critical   interest    in   orecise   enough   terms   to  meet    the 
assumptions    of  most   of  the    models   that    are   made    available. 

We    function   very   well   in   very   small   discrete   and   limited 
areas    of  measurement.      The    more    we    learn,    the   more   we    study 
in   science,    including  psychology,    the    more    we   begin   to  under- 
stand  some    of   the    limitations    of  measurements   that    we  have 
available    for  those    models   which   are    complex,    which    are    multi- 
varied   or  which   handle   many,    many   different    variables   at    the 
same    time.      At    present,    they   take    more    rigorous    assumotions 
that   we    can   hooe    to  meet,    therefore,    we    concentrate    on   very 
narrow   functions,    functions    of  a   more   ohysical  nature,    ones 
which   are    immediately   applicable    to  models   that   are    available. 

We   have    got   to   develop   much   more    sophisticated  techniques 
within   psychology   and  then    get    together  with   other  disciplines 
who   have    managed  to   generate    models   which   are    already   compli- 
cated enough,   which   make   too  many   demands    on   the   kind   of 
things   we   deliver   and  not    so   much   on   new  models  per   se . 

We   need  new  techniques    for  measuring  some    of  what    I   might 
call  the    fussier  dimensions    of  human  behavior,    fussier  partly 
because   they   are   difficult   to   define.      Also,    they    give    us 
difficulty   because   many,    many  elements   in  them  which   we    cannot 
control   or  analyze    in   the    laboratory  exists    out    in  the    field. 
We    haven't   been  able    to   describe   these    completely  enough   yet 
and   in  precise   enough   terms    to  plug   into  the   models    the    oper- 
ation  researchers    have    developed. 


176 


DR. 

TEARE 

:   I  will  have 

to  be 

discrete 

Dn,  as 

well 

as  time, 

would 

Our 

particular 

concern 

right  i 

practice 

,  i.e. 

,  the 

actions 

that  a 

QUESTION   DIRECTED  TO  DR.    TEARE:      What    is    involved  in 
evaluating  successful   clinicians   and  clinical  procedures? 

very   brief  because   I   think 
indicate    that    I    do   so. 

now  is   describing  clinical 
clinician   take s   in   deal- 
ing with  a  patient   within   the    setting  of  a  practice ,    as 
differentiated   from  the    technical   information   and  the   kind 
of  manual   or  technical   skills  that   he   can   bring  to  bear.      So, 
the    first    steD   is    one   of  description   in   very  precise   and 
meaningful  terms.      We   are   using  a  technique   known   as   the 
critical   incidence    device    for  this. 

The    second  step   is   separating  actions  taken   toward  the 
Datient   into   those   actions   which   can   be    seen   to  have   clear- 
cut  effects   and  consequences   of   little    or  no   identifiable   value. 
It   is   already  becoming  clear  that   the    great  bulk   of  what  a 
clinician   does  to   the   patient   is   of  the    latter  tyoe.      However, 
just   as   the   advertising  man   is   quoted  as   saying,    "fifty  per- 
cent  of  my  budget    is   wasted — I   wish   I  knew  which   fifty  percent." 

If  much   of  what   we   do   does  not   make   any   difference,    we 
have    got   to   separate   this   out,    the    ineffective    from  the 
effective.      Then   once    these    are    determined,    we   again   go   back 
to  the   problem  I   was    referring  to. 

We   have   to   generate   ways    of  measuring  and   describing 
the    conditions  under  which  the    desirable   behavior  takes 
place,   ways    of  measuring  this  effective    clinical  performance 
and  translating  it    into  terms    of   instruments. 

QUESTION    DIRECTED  TO   THE    PANEL:      One    final   question: 
recognizing  the   necessity   for  a  multidisciplinary  approach  and 
that   it   is   highly   desirable    for  both  health   care    and   research 
problems,    isn't   there    a   danger   of  not    being  able    to   "see    the 
forest    for  the    trees",    and  who   is    going  to  be   the    "leader"    of 
the    team? 

ANSWER   BY  DR.    TEARE:      A    few  months   ago,    we   were    down   at 
Gainesville,    Florida,    studying  a   college   of  health-related 
professionals.      The   particular   concept   that   was   at   work   in 
this   college   was  the   team  approach,    the   paramedical  aporoach 
in   medicine. 


177 


As  part   of  the    conference   that   was   taking  place,   the 
team  approach  as   such  came   under  attack.      First   of  all, 
parenthetically,   when  we   would  visit   and  Interview  each 
department   within  the   college,   we   would  then  ask    (and  while 
at    first    this   was   merely  naivete,    after  a   while    it   became 
with  malice    aforethought)    we   would  ask   where   the   next 
department   was   and  we    found  out   in  this   huge   comolex   of 
integrated  paramedical  team  approach,   ohysical   therapists 
didn't  know  where   the   OB  Department    was,   the   occupational 
therapist    did  not   know  where    the    rehabilitation   division 
was    located,   and  so   forth.      My   answer  to  this   was   that 
the    "integrated  team  aoproach"    seemed  a   bit   over-played,    at 
least   at    oresent. 


ANSWER   PROM   MR.    HOLDER:      I    would    like    to    comment    on   two 
different   levels.      The    National   Commission   on   Community 
Health   Services   has   a'Task  Force'1  on   comprehensive   personal 
health    services,    and  they   are    concerned   that   once   a  oerson 
is   identified   with   the   expressed  need  with  which   he    comes 
into  the   health    system,    he   usually   stops   there    or  incomplete 
referrals   are    made. 

So  they   are   proposing  that  each  person   or  family  needs 
a   general   health   counsel  or  general  health  practitioner 
or  something  of   this   nature    for  the    overall   health    look, 
but    it    is   the    responsibility   of   the   portal  entry--whether 
it    be    the   optometrist's   office    or  the   emergency   room   of 
the   hospital   to  take    a   look  beyond   the    immediate   problem 
and   be   cognizant   of  the    total  need  of  the    individual. 

Secondly,    my   concern   has   been   that    we    are   not    using, 
within  the    community,   the    technological   resources   we 
have    now.      It    is    like    the    old   farmer  who  was   urged   to 
go  back   for  an   agricultural   course   and  he   said,    "Why 
should  I   go  back?      I   am  not    farming  now  as    good  as   I 
know  how  to." 

So  we   have   to   do    something  to   reduce   this   behavioral 
gap.      It   is   my   opinion   whoever  perceives   a   community  need, 
has   the    responsibility,    I   think,    to  bring   others    of   like 
mind   together  to   work   on  a   coordinated  basis.      Here    is 
what    I   think   is    the   need,    what   are    we    going  to   do   about 
it?      I    think   that   there    are    individual   responsibilities    and 
there    are    community   responsibilities. 


178 


ANSWER  PROM  DR.    DAVIS:      As   optometrists,   most  of  us   think 
in  terms   of  individual   clinical  practices.      We   worry  about 
who   will   be    captain  when   we   do  begin   working  as   a   team.      It 
will   more    than   likely  not   matter  who   becomes    caotain.      In 
practice    the    captain   is    often   the   team  member  who  assumes 
the    responsibility.      In   many   cases   this   will   be    the 
member  who    first   brought   the   particular  patient   to  the 
attention   of   the    team.      In   other  cases    it    is   the    man    for 
whom  the   patient   has  the    most   confidence   and  respect. 

Nobody  wants   the    responsibility,   however,    so   I    really 
feel  that   the    captain   will   be   whoever  has   the   nerve    to 
assume   the    responsibility  to    see    that   the   patients    get    the 
total   care. 


ANSWER  FROM  MR.    HOLDER:      It   seems   to  me    that,    practically 
speaking,    in  these    days    of  specialization,   every   individual 
patient   is,    in   a   sense,    becoming  his    own   diagnostician. 

It    is   he    who   figures    out   what   his   ailments   are    in 
order   for  him  to    select   the   kind  of  practitioner  to  whom 
he    goes.      If  I   have   a  problem,    do   I   go  to    an   internist, 
or  to   whom   do    I    go? 

So   I   select   one    out   of  the   phone   book   or  something 
like    this.      I   may   be    completely   off,    but   I   am  making  my 
own   diagnosis. 


ANSWER   FROM  DR.    HUNTER:      I   would    like    to   say    this    is 
the    reason   with   Head  Start   that  we   have    come    back   to 
screening.      With    screening,    you   get   at    least    some    clue 
as    to   what   the   problem  is   and  there   you  have   a   referral 
system  to    at    least   lead  them  to   some   place    where    they   can 
have    definitive    care. 


ANSWER  FROM   MR.    DUPRESS:      There    is    an   ever   increasing 
amount    of  apolied   research  in  the   area   of  the    aged  oopulation, 
including  the   partially   sighted.      This    research  usually 
begins   with   two   assumptions:      (1)    The    aged  have    unlimited 
problems   which    should  be    studied,    and    (2)    Studies   should  be 
confined   to   institutions    for  the    aged,    since    groups    of   old 
people   are    readily   available.      It    seems   to   me   we    are   missing 
a   great    deal   of  important    data   if  we   concentrate    on   the 
institutionalized  aged.      The   better  approach    is    to    study 


179 


aged  people   living  independently;   the   institutional   group 
would   serve   as   a  control.      We    should  study  those   who  are 
able   to    read  extensively,    to    determine   whether   it    is 
simply   a  matter  of   their  having  better  vision,   higher 
motivation,    or  the    fact   that   they   are    challenged  to  be 
more    creative   when   they   are   not    institutionalized. 

The    interests   of  the   aged  are    as   varied  as   those   of  the 
rest    of  the   population.      In   presenting  material  to    older 
persons,   which   they   may   read  with   low  vision   devices    or  in 
the    form   of  clear  type,   we    should  be    completely   aware    of 
the    scope   of  their  interests.      A    great    deal  of   research 
will   be   wasted  if  we    look   upon   aging  as   a   collosal  problem. 
Rather,    in  the    course    of   our  research,   we    should   sort   out 
those    factors   which   enable    a   significant  percentage    of 
aged  people    to   be    very   alert   and   competent   in  their  70s, 
80s   and  even   90s.      Emphasis   on   the  positive,    and  our 
ability  to   create    a   more    active    life    for  all  aged  people, 
should  be    our   goals.      For  the    most  part,    older  people 
are   not   unlike   the    rest   of  the   population,   except   for  the 
fact   that   they   are    older. 

Deterioration    in   sensory   channels,   general  health, 
memory   capacity   and   the    ability  to  process  new   Information 
may   go   along  with   aging,   but    being  handicapped   does  not 
necessarily    lead   to   disability.      Instead,    it   may  provide 
a   challenge   which   many   older  persons    are   able    to   overcome. 
It   is   this  positive    side    of   aging  that   deserves   the    most 
investigation,    for  it    is   here   that   we   will   find   solutions 
to   most   of  the   problems  which  the    aged   face    in  maintaining 
worth   and   dignity. 


ANSWER  PROM  DR.    TEARE:      I    feel  that,    from  Mr.    Dupress, 
I   should  descend.      I   was  hoping  that   the   material   of  my 
illustration   would  give   you  the   true   picture    of  how  I   felt 
about   the   team. 

In  medicine,    as   most  of  you  well  know,   there    is   the 
question   of  how  to  integrate    or  how  to  marshall   the   specialty 
resources    that   can  be   brought   to  bear  on   a  particular  patient, 
on   a  particular  illness   at    some   point   of  time.      The    family 
physician   is   viewed  as   a  crucial  member  of  the    team  usually 
because   the    first   contact  has   been   made    out   of  general 
practice. 

The   American   Society  of  General   Practice    is   working  very 
hard  at   trying  to  define    the    role   that   such   a   family  physician 
might  play.      Whoever  serves   as   the    initial  patient   contact, 


180 


must   be    someone    who    is    knowledgeable    of   the    special   skills 
of   the    various   professions   there    and   who  can   serve    a   very 
critical   referral   function   as    well   as    a   coordinating 
fun  c  t  i  on . 

As   Dr.    Davis    says,   when  paramedical  teams    include    a 
physician   of  some    specialty   and  he    is   known   to  be    a 
physician,    in   the    last   analysis   the    final   legal   responsibility 
falls   to  the   physician  member.      All   other  thinpcs    being 
equal,    regardless   of  what   the    soecial  problem   is    in   whose 
cubicle   the   main  oroblem   falls,    the   patient   will   always 
look,    legally,    to   the   physician    if  suit    is    involved  and 
not   to   the    occupational  therapist   or  the   nurse. 

In   this    mix  of   health    skills  needed   for  interdisciplinary 
health    care   when   one   person  has    a   legal   responsibility   that 
is   way    out    of  proportion   to   the    others,    he    is    going  to 
assume    leadership   whether  he    wants    it    or  not   and  whether 
it    is    aporooriate    in  this   kind   of  case. 


ANSWER   FROM  DR.    GAYNES*:      On   the    "captain  of   the    team" 
issue,    let    me    quote    one   educator's    viewpoint    develooed   in 
a   situation   I   have   encountered. 

A   consultant    in   Special   Education    for  a   large    school 
district   asked   me    and   the    ophthalmologist    who   serves    as 
co-director  of   our   Low  Vision   Clinic,    to    act   as    consultants 
in   planning  the   education    of   visually-imoaired   children  in 
their  school    system.      The   educator   raised   the    question,    as 
did  we,    as   to   whether  some    of   the   children    should  be   educated 
along  sighted   lines    or  was    their  training  to   be   entirely 
Braille. 

The    difficulty   in  attemoting  to   categorize   these,    as    all 
children,    was   that   the    children   refused   to   fall   into   specific 
categories.      There   were    children  whose    vision   was   poor  who 
might  be    considered   good   candidates    for  Braille,    but   their 
fingers,    not    being  sensitive    to  touch,    or  other   sensory 
disturbances,   made    Braille   education    difficult.      There 
were    children   with   low   vision   who  had  emotional  problems, 
and   some  had   orthopedic  problems.      In    short,    these    children, 
from  an  educational   standpoint    as    well   as    a  physical   standpoint, 
did  not   belong  to   any   one   area   of  specialization. 


*0.D. ,    Low  Vision    Clinic,    Sinai   Hospital   of  Detroit,    6767 
West    Outer  Drive,    Detroit,    Michigan,    482  35.       (Offered  as 
a   comment    from  the    floor) 


181 


The   educator  stated  that  they   had  had  consultants  in  the 
various   specialties   for  years,   but    often  did  not    learn 
enough  about   the    children  to  plan,    adequately  and  intelligently, 
an  educational  program.      He   raised  the   question   as   to  whether 
a   "team"   approach   might  be   the    most  useful  way   of  viewing 
these   youngsters.      However,    in   our  discussions,   it   was    felt 
that    in   a  "team"app roach   which   simply   meant  that   there   were 
a  number  of  specialists   involved,    but   that   the    specialists 
would  operate    independently   and  view  the    child  independently, 
this    would  only   continue   the    old   system. 

It    was   felt  that    if  the   information  were   assembled 
separately,   the    conclusions   would  not   necessarily   be   the 
same    as  when  there   was   an   interplay  between  all  members 
of  the   "team"   as   they   viewed  and   discussed  the   child  to- 
gether.     This   should  be    considered  when  looking   at   special 
problems  which   require   a   greater  imagination  and   solution. 
We    should  not   be   deluded  into   thinking  that  having   a  great 
number  of  people    separately    look  at   the  problem  is   the 
equivalent   of   a  true    "team"    approach.      I   would   suggest   that 
all   of  the   "team"    approaches    occur  simultaneously. 


182 


c.3 


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WWW 

Ai21 

Ai21 

_  Aid  to  the   Visually 

AUTtHdtilited,    ConfeEence  on. 

PROCEEDINGS.  Washington 

T,TLEMarch  2ii&25,   1966. 


c.  3 


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BORROWERS   NAME 


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AMERICAN  FOUNDATION  FOS  THF.  BLWrt 
X      15  WZ3T  IGih  STREZi 
X   NEW  YORK,  N.Y.  10011